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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) DT1504 4/2009 s.86.07(2)Wis.Stats.&Ch.Trans 231 Wis.Adm.Code • This form is an application for permission for a STH Connection.If approved,the Document Identification Number. permit does not create a right of access or access easement for the property. 13-100125366-2014 • If the property has any legal restrictions that prohibit access to a state trunk highway t 2 (STH),WisDOT cannot approve a STH connection permit for the property. 0 4 Wisconsin DOT • Please type or print neatly in ink.Fill out the required information on both sides p o SW Region-Madison Office of this form per the instructions.One form is required per connection.For more o z 2101 Wright St. information,visit: ,, mpy... property deed _. Madison,WI 53704 • Please provide a co of the with all applications. 1.Applicant Name and Mailing Address-Street/PO Box,City,State,ZIP Code 2.Property Owner Name/Address(If not applicant) Frank&Dana Seltzner Robert&Deanna Sheehy z 4 savannah Parkway 971 Sand Pipper Ct. n a Deerfield,WI 53531 Sun Prairie,WI 53590 cl n. Q Z 3.If Not Property Owner,Reason for Application Purchasing 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway °- 19 Dane of:Medina 0 North ®South ❑East ❑West a 0 0 8.Located within the 9.Fire or Street Number(If applicable) 0 F z 4 Quarter,of the Quarter,Section 7,Town 8 North,Range 12 o � 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the w z nearest non-side road connection z Prospector Lane 970 ft East on the same highway? 150 ft (Feet or Mdes) (N,S.E,W) {Feet or Miles) V Log Mile or Reference Point(Filled in by WisDOT): RP= 040+1.08 w 12. Proposed Activity 13.Proposed Use(Check one—See instructions for category description) 16.Proposed Trips Per Day(Check one) H a (Check one) ❑Urban—Commercial/Industrial Cl Rural-Agricultural 1:7 Seasonal ❑101-1000 z ❑Urban-Residential ❑Public Road ® 1-50 ❑Over 1000 o < 0 Construct New ❑Rural-Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 ❑Alter Existing ® Rural-Residential z w ❑ Remove Existing Peak hour traffic count: z z Is this a change of the existing use(If applicable)? ❑Yes ❑No 0` ®Permit Existing t.) 14.Proposed Width:20 ft 115.Proposed Surface:gravel QUESTIONS 17-27 on BACK PAGE All connections have restrictions,which include the information preprinted The applicant affirms that all information provided on and submitted and filled-in on this application along with any conditions, covenants, with this form is correct result con pe m. denial or incorrect s supplemental provisions,superimposed notes,and detail drawings added well as criminal information prosecution may ruder. permit iscol or rSvocaes. as by WisDOT. The applicant shall be responsible for complying with these well as criminal prosecution under s.946.32 Wisconsin Statutes. restrictions along with the construction and maintenance of the connection. It is further understood that WisDOT's approval is subject to applicant's full X 714416 Set/pet 10/13/2014 compliance with relevant state statutes and administrative rules, plus any (Property Owner or Authorized Representative) (Date) laws, codes, rules, regulations, ordinances and permit requirements of (If Computer-filled,Brush Script Font) other jurisdictional agencies.The alteration of this form by the applicant is prohibited.Under s.86.073 Wisconsin Statutes,WisDOTs permit denial or revocation may be appealed. (Area Code and Telephone It) (E-mail address if available) FOR OFFICIAL WISDOT USE ONLY-DO NOT WRITE BELOW THIS LINE ❑THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ® Permit APPROVED(THIS PERMIT IS REVOCABLE) ❑ Permit DENIED ❑ Application DISMISSED X Scot qiotate 10/17/2014 (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font) ❑Temporary permit.Expiration date: ®This permit voids/replaces permit# 11-15-03 ❑ Shared Co-user name: connection Related permit# File: