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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) 011504 4/2009 s 86 07(2)Wis Stats &Ch Trans 231 W is Adm Code • This form is an application for permission for a STH Connection If approved,the Document Identdicalron Number iu permit does not create a right of access or access easement for the property 2 z 13-100199108-2015 • If the property has any legal restrictions that prohibit access to a state trunk highway w g (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 a SW Region-Madison Office of this form per the instructions One form is required per connection For more ra co i 2101 Wright St information,visit www dot wisconsin qov/business/rules/property-permits htm - Madison,WI 53704 • 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 William and Sheryl Rickerman z °- N11471 State Road 26 st 0 < Waupun WI 53963 J a. a a li o Q z 3 If Not Property Owner,Reason for Application z 4 Highway Number(s) 5 County 6 ❑City ❑Village ®Town 7 Side of the Highway o '12/18 Dane of Cottage Grove ® North ❑South ❑East ❑West ¢ - - o O 8 Located within the 9 Fire or Street Number(If applicable) _t Q z < NW Quarter,of the NE Quarter,Section 32,Town 7 North, Range 11 E , 2760 o z I- 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 W Vilas Road 930 feet West on the same highways N/A o (Feel or Miles) (N,S,E,W) (Feet or Mdes) U Log Mile or Reference Point(Filled in by WisDOT) RP=360M+034 m 12 Proposed Activity 13 Proposed Use(Check one--See instructions for category description) 16 Proposed Tnps Per Day(Check one) a. a (Check one) ❑Urban-Commercial/Industrial ❑ Rural-Agricultural ❑Seasonal ❑101-1000 i- ❑Urban-Residential ❑Public Road IA 1-50 ❑Over 1000 z• < El Construct New ®Rural-Commercial/industrial ❑Trail or Trail Crossing ❑51-100 O▪ re ❑Alter Existing ❑Rural-Residential z LL ❑ Remove Existing Peak hour traffic count 4 z z Is this a change of the existing use(If applicable)? ❑Yes ❑ No o'� ®Permit Existing U 14 Proposed Width N/A 15 Proposed Surface N/A QUESTIONS 17-27 on BACK PAGE The applicant affirms that all information provided on and submitted All connections have restrictions,which include the information preprinted with this form is correct and complete. Providing incorrect or and filled-in on this application along with any conditions, covenants, incomplete information may result in permit denial or revocation as supplemental provisions, superimposed notes,and detail drawings added well as criminal prosecution under s.946.32 Wisconsin Statutes. by WisDOT The applicant shall be responsible for complying with these restrictions along with the construction and maintenance of the connection ` It is further understood that WisDOT's approval is subiect to applicant's full X C `• �, i%\1 C tiS compliance with relevant state statutes and administrative rules, plus any (Property Owns or&uthortzed Representative) (Date) laws, codes, rules, regulations, ordinances and permit requirements of (If Computer-1ille rhsh Script Font) other jurisdictional agencies The alteration of this form by the applicant is l t prohibited Under s 86 073 Wisconsin Statutes,WisDOT's permit denial or (rib$ ca.' (3,651: SC.r 1 v�nccu Y1p-tt"1wu.%1 •Co` i revocation may be appealed (Area Code and Telephone#) (E-mail address if available) FOR OFFICIAL WISDOT USE ONLY-DO NOT WRITE BELOW THIS LINE C]THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ❑X Permit APPROVED(THIS PERMIT IS REVOCABLE) ❑ Permit DENIED ❑ Application DISMISSED X --7 �0/-- 12/03/2015 (WisDOTAuthoriized Representative) (Date) (If Computer-filled,Brush Script Font) ❑Temporary permit Expiration date ®This permit voids/replaces permit# 13-14-75 ® Shared Co-user name TRANCHITA connection Related permit# 13-100198947-2015 File