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d DOCUMENTATION OF AUTHORIZED CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) DT2234 6/2006 s.84.25 Wis.Stats. • This form is NOT a permit. It serves to document an STH connection regarding its L type, configuration,drainage,etc.,for a property in which WisDOT authorized an LL o Wisconsin DOT access point under a previous s.84.25,Wis.Stats. project. O SW Region-Madison Office • Use only one DT2234 form for each connection. When work in the highway right-of- G o 2101 Wright St. way is also needed, use form DT1812 together with form DT2234. w z u. Madison,WI 53704 • Please include a copy of the property deed. 1.Property Owner Name and Mailing Address—Street/PO Box,City,State,ZIP Code 2.Property Owner Area Code+Telephone Number re z Dan&Jill Sears 702 556-9911 ° 216 Thomson Ln 0 Oregon,WI 53575 re 0 3.Property Owner E-Mail Address w U- 0 a. Z npboy100 @gmail.com re a • 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway o▪ 138 Dane of:Rutland ❑North ®South ❑East ❑West ,s< 0• _ 8.Located within the 9.Fire or Street Number(If applicable) —J • < NE Quarter,of the NW Quarter,Section 8,Town 5 North, Range 10 East o ▪ 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the nearest non-side road connection z z• z Hill Road 1600 ft East on the same highway? 125 ft o (Feet or Miles) (N,S,E,W) (Feet or Miles) V Log Mile or Reference Point(Completed by WisDOT): RP=017+0.54 m 12. Proposed Activity 13.Proposed Use(Check one) 16.Proposed Trips Per Day(Check one) a. C (Check one) ❑Urban—Commercial/Industrial 0 Rural—Agricultural 0 Seasonal ❑ 101-1000 z r= ❑Urban—Residential ❑Public Road ® 1-50 ❑Over 1000 o < ❑Construct New F 2 ❑Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 w o Alter Existing ®Rural—Residential z LL ❑Remove Existing Peak hour traffic count: z z g Is this a change of the existing use(If applicable)? ®Yes ❑No o— ❑Document Existing ✓ 14.Proposed Width: N/A 115.Proposed Surface: N/A 17. ®Yes ❑No Is the property zoned? Include documentation from the jurisdictional zoning authority. 18. Explain how the land is currently being used: Residential 19. ❑Yes ®No Does the property owner have any plans to change the zoning or land use for the property? If yes,explain. Note:Items 20 and 21 purposely omitted 22. ❑Yes ®No Does the property abut or border another public road? If yes, provide the road's name. 23. ®Yes ❑No Are there any existing connections serving the property? If yes,how many? 1 24. ®Yes ❑No Are there any restrictions on the number,use,or location of connections to the property? If#24 or 25=yes",have copies of all documents relevant 25. ❑Yes ®No Are there any access easements across the property to the restrictions and/or easements been provided? (recorded or unrecorded)? 26. Provide the property tax identification number: 0510-081-9100-0 ❑ Temporary. Expiration date: SEE BACK PAGE FOR identification Number ❑ This voids/replaces permit number: CONDITIONS OF ISSUANCE 13-100191547-2015 Co-user name: Rogowki ® Shared connection Related ID number. 13-100192927-1 3-1 0 0 1 9 2 9 2 7- x 2015 11/09/2015 (VVisDOT Authorized Representative) (Date) File: (If Computer-filled,Brush Script Font)