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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 cwi 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 g SW Region Madison Office • Use only one DT2234 form for each connection. When work in the highway right-of- 2101 Wright St. way is also needed,use form DT1812 together with form DT2234. z 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 cc z z Leslie Swanson ° 1022 S. Perry Pkwy. a Oregon,WI 53575 ° 3. Property Owner E-Mail Address a a o z 0 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway o▪ 138 Dane of: Rutland ❑ North ® South ❑ East ❑West 0 0 8.Located within the 9.Fire or Street Number(If applicable) J H z a NW Quarter, of the NW Quarter, Section 8,Town 5 North, Range 10E o P- 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 100' • — Hill Rd. 320' East on the same highway? o (Feet or Miles) (N,S,E,W) (Feet or Miles) • Log Mile or Reference Point(Completed by WisDOT): RP=017+0.77 w 12. Proposed Activity 13.Proposed Use(Check one) 16.Proposed Trips Per Day(Check one) o.>— o (Check one) ❑ Urban—Commercial/Industrial ❑ Rural—Agricultural ❑ Seasonal ❑ 101-1000 z• a ❑ Construct New ❑ Urban—Residential ❑ Public Road ® 1-50 ❑ Over 1000 w ❑Alter Existing o ❑ Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑ 51-100 ® Rural—Residential z ❑ Remove Existing Peak hour traffic count: o ? Document Existing Is this a change of the existing use(If applicable)? ❑Yes ❑ No U 14.Proposed Width: 18' 115. Proposed Surface: Asphalt 17. ®Yes ❑ No Is the property zoned? Include documentation from the jurisdictional zoning authority. 18. Explain how the land is currently being used: RHI Building a new home 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: 0510-082-8500-0 ❑ Temporary. Expiration date: Identification Number SEE BACK PAGE FOR ❑ This voids/replaces permit number: CONDITIONS OF ISSUANCE 13-2681-08 ❑ Shared Co-user name: connection Related ID number: X � 7-28-08 File: (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font)