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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) DT1504 9/2009 s.86.07(2)Wis.Stets.8 Ch.Trans 231 Wis.Adm.Code • This form is an application for permission for a STH Connection.If approved,the oowmsra Identification Number: permit does not create a right of access or access easement for the property. 13-100204969-2016 • If the property has any legal restrictions that prohibit access to a state trunk highway m g (STH),WisDOT cannot approve a STH connection permit for the property. O ►- Wisconsin DOT • Please type or print neatly in ink.Fill out the required information on both sides of i- a O c SW Region-Madison Office this form per the instructions.One form is required per connection.For more 0 =u. 2101 Wright St. information,visit: httD://wisconsindot.00v/Pages/doino-bus/real- estate/permits/default.aspx g Madison,WI 53704 • Please •rovide a co• of the •ro•ert deed with all a••lications. 1.Applicant Name and Mailing Address-Street/PO Box,City,State,ZIP Code 2.Property Owner Name/Address(If not applicant) z Trever and Christen Otto i ° 408 Azurene Ln 3 a Verona,WI 53593 J K o.4 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 ▪ 92 Dane of:Primrose ❑North ❑South 0 East ®West c 0 8.Located within the 9.Fire or Street Number(If applicable) z NE Quarter,of the NE Quarter,Section 11,Town 5 North,Range 7 East -• a 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 Spring Rose Road 1,320 ft South , on the same highway? 560 ft o (Feel or(elies) (N,S.E.W) (Foot or Mks) U Log Mile or Reference Point(Filled in by WisDOT): RP=014+0.25 W 12. Proposed Activity 13.Proposed Use(Check one—See instructions for category description) 16.Proposed Trips Per Day(Check one) u. z (Check one) ❑Urban—Commercial/Industrial ❑Rural—Agricultural r- o ❑Seasonal ❑101-1000 z i i= ❑Urban-Residential ID Public Road ® 1-50 ❑Over 1000 ®Construct New ❑Rural-Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 ❑Alter Existing ®Rural-Residential ii ❑Remove Existing Peak hour traffic count: z— Is this a change of the existing use(If applicable)? ®Yes ❑No ❑Permit Existing 14.Proposed Width:24 ft 115.Proposed Surface:gravel QUESTIONS 17-27 on SACK 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 prosec on 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 WsDOT's approval is subject to applicant's full X 47/01/6' 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 other jurisdictional agencies.The alteration of this form by the applicant is prohibited.Under s.86.073 Wisconsin Statutes.WisDOT's permit denial or (C),t0)74'o-6,4/g r +rv/l 0.(t• J civ-.,A.: I.cam revocation may be appealed. (Area Code and Telephone a) (E-mail addres&if available) FOR OFFICIAL WISDOT USE ONLY-DO NOT WRITE BELOW THIS LINE ®THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ® Permit APPROVED(THIS PERMIT IS REVOCABLE) 1.The existing driveway located 150 ft.south of this driveway will ❑ Permit DENIED need to be removed as a condition of this permit. Refer to permit ❑ Application DISMISSED number 13-100204970-2016. X �� 04/08/2016 (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font) ❑Temporary permit.Expiration date: ❑This permit voids/replaces permit# ❑Shared Co-user name: connection Related permit#