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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Trans rtation DT1504 4/2009 s.86.07(2)Wis.Stats.&Ch.Trans 23 Wis.Adm.Code • This form is an application for permission for a STH Connection.If approved,the pi permit does not create a right of access or access easement for the property. t Document identification Number. • If the property has any legal restrictions that prohibit access to a state trunk highway (;j F° (STH),WrsDOT cannot approve a STH connection permit for the property. g • Please type or print neatly In ink.Fill out the required information on both sides l"' ni of this form per the instructions.One form is required per connection.For more g z information,visit: www.dot.wisconsin.00v/business/ruleslorooerty-oermits.htm • Please provide a copy of the property deed with all applications. 3 1.Applicant Name and Mailing Address-Street/PO Box,City,State,ZIP Code _ 2.Property Owner Name/Address(If not applicant) 4 o J r 1i' yNE✓Z � RoY �: RNY.t1 EYZ � 2 pi}-r i', c/A s, a- Y�C�1 �-fi 2 C» s R� y�� a. 0 <z y J /Z1 013 s e vt t/, 1-0 it y /C d 1 3.If Not Property Owner,Reason for Application G 1?%> Cs P/t ix,5 U I 53 52$7 z o 4.Highway Number(s) 5.County 6. 0 City ❑Village VI To 7.Side of the Highway P. 78 7O 5 J7A of: el a e lid wN dS ❑North ❑South ❑East al West J g 8.Located within the ` t .�. cc n o� E.--/ 9.Fire or Street Number(If applicable) Z < SEQuarter,of thb5 arterf&actiona.7Town North,`Range oz , to.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the wz o f u ,Q_G pr 3 y� /5$y/�-0 nearest non-side road connection 0 U i Ro k PQ f (Feet or Wee) Q' S E on the same highway? l .2 a t` Log Mile or Reference Point(Filed in by WisDOT): R P_ o(p y.,� 0. 5--/ (Feet or Mie re 12. Proposed Activity 13.Proposed Use(Check one-See instructions for category description) 16.Proposed Trips Per Day(Check one) y. z (Check one) t- z o ❑Urban—Commercial/Industrial ❑Rural—Agricultural ❑Seasonal ❑101-1000 a _Construct New 0 Urban—Residential ❑Public Road 1-50 f- ❑Rural—Commercial/industrial 0 ❑Over 1000 m o ❑Alter Existing ❑Trail or Trail Crossing z z ❑Remove Existing Rural—Residential 9 ❑51 100 z z Is this a change of the existing use(If applicable)? ta Yes ,.�No Peak hour traffic count: ❑Permit Existing 114.Proposed Width:A iir 115.Proposed Surface: armiei, QUESTIONS 17-27 on BACK PAGE Al connections have restrictions,which induce the information preprinted The applicant affirms that all information provided on and submitted and filled-in on this application along with any conditions, covenants, inco this form is correct and complete. denial or ivocatiotas or supplemental provisions,superimposed notes,and detail drawings added incomplete information may result In permit denial or revocation 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 WisDOTs approval is subject to applicant's full X compliance with relevant state statutes and administrative rules,plus any q/d/ laws, codes, rules, regulations, ordinances and permit requirements tPfOPerty Owne or thorized eq of �entative D>� other jurisdictional agencies.The alteration of this form by the applicant is (!f Computer fitted,Brush Font), ) ( �} prohibited.Under s.88.073 Wisconsin Statutes,WrsDOT's permit denial or ggLJ.- /r)2—+_ n revocation may be appealed. (Area T le /firll I ass available) c�ble) /f,�Q f (Area Code and Telephone it) E-ma' dressy available} FOR OFFICIAL WISDOT USE ONLY—DO NOT WRITE BELOW THIS LiNE NI THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY M Permit APPROVED(THIS PERMIT IS REVOCABLE) Permit DENIED A iy,jk n i'►vn,, Cu/v-erf s r�U�raj ❑ Application DISMISSED W;#._ error-% 4-Aid u,a �(S% / X '' 2. 1),-;./14. s,L/I 5-4p, S/.1 4 (WisDOT Authorized presentativ ) �Date) �-r ��c tN a /�4$ e Q (if Computer-filled,Brush Script Font) ( ) S K s>� 5 L11 J ii ❑Temporary permit.Expiration date: oy leer- �(ro,I-Gt . / ❑This permit voids/replaces permit# ❑Shared Co-user name: connection Related permit# File: