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APPUCATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department-of-Transportation(WisDOT) — DT1504 9/2009 a.86.07(2)Wis.Stets.&Ch.Trans 231 Wis.Adm.Code • This form is an application for permission for a STH Connection. If approved,the permit does not create a right of access or access easement for the property. w Document Ide 'Mon Number • If the property has any legal restrictions that prohibit access to a state trunk highway Z 3-A10/V0707- !s (STH),WIsDOT cannot approve a 8TH connection permit for the property. • Please type or print neatly in ink.Fill out the required information on both sides of I-- 1 this form per the instructions.One form is required per connection. For more S o information,visit: htto://wisconsindot.gov/Pages/doino-bus/real- �t i estate/permits/defauk.aspx 3 • Please provide a copy of the property deed with all applications. 1.Applicant Name and Mailing Address-Street/PO Box,City,State,ZIP Code 2.Property Owner Name/Address(If not applicant) z Eric Schutt z 0 2675 Tower Road _ 0 .t McFarland,WI 53558 as.. E a ? 3.If Not Property Owner,Reason for Application 0• 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway i 51 Dane of Dunn ❑North ❑South 0 East West JF 8.Located within the 9.Fire or Street Number(If applicable) o NW Quarter,of the NE Quarter,Section 22,Town 6 North, Range 10 w z 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the z— y nearest non-side road connection o Dyreson Road / 8� �O r'7 r4 on the same highway? 200 feet o �Fer Alles) fir,S.E.W) (Feat or Mies) Log Mile or Reference Point(Filled in by WisDOT): R p t 05-€1-74 a 3 I( d 12.Proposed Activity 13.Proposed Use(Check one-See instructions for category description) 16.Proposed Trips Per Day(Check one) z (Check one) C ❑Urban-Commercial/Industrial ❑Rural-Agricultural 9 0 Seasonal 0 101-1000 o d ❑Urban-Residential ❑ Public Road 1-50 ®Construct New ® ❑Over 1000 o a ❑Alter Existing Rural-Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 ❑Remove Existing ®Rural-Residential z z g ❑No Peak hour traffic count: o r ❑Permit Existing is this a change of the existing use(if applicable)? 0 Yes 0 14.Proposed Width:20 feet 115.Proposed Surface:Asphalt QUESTIONS 17-27 on BACK PAGE All 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, with this form Is correct and complete. Providing or ivocrreon s supplemental provisions,superimposed notes,and detail drawings added well u:or s Information may result In permit denial or revocation as by WIsDOT.The applicant shall be responsible for complying with these w as c' Fnal proses nder s.848.32 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 a. compliance with relevant state statutes and administrative rules,plus any 7/27/15 laws, codes, rules, regulations, ordinances and permit requirements of (Property Owner or Authorized Representative) (Date) other Jurisdictional agencies.The alteration of this form by the applicant is prohibited.Under s.88.073 Wisconsin Statutes,WIsDOT's permit denial or 608_239_9656 revocation on may appealed. EricSchuttaaol.com revoca (Area Code and Telephone#) (E-mail address If available) FOR OFFICIAL WISDOT USE ONLY-DO NOT WRITE BELOW THIS LINE gi THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY Permit APPROVED ED(THIS PERMIT IS REVOCABLE) d ❑ Permit DENIED j• n n,‘,,,t v"' sr Ze. C u I, /"" Q hawe ,0 Application DISMISSED is l:7A-cit.r. .7,0___.....7/.46 or/es- 7.. cv ltAA-r(- 10, (l r:0-0 or4✓ exvot`""0A (Wis Authorized Representativh) (If Computer-filled,Brush Script Font) ❑Temporary permit. Expiration date: ❑This permit voids/replaces permit# Shared Co-user name: connection Related permit#