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3/12/2009 Sam Fisher SPO PDF 0312131853 001 pdf „ ..., Page 2 • 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 type;configuration,drainage,etc.,for a property in which WisDOT authorized an IT- 0 Wisconsin DOT access point under a previous s.84.25,Wis.Stats.project. a SW Region-Madison Office • Use only one DT2234 form for each connection. When work in the highway right-of- p o 2101 Wright St. way is also needed,use form DT1812 together with form DT2234. a_ i. Madison,WI 53704 • Please include a copy of the property deed. • 1.Properly Owner Name and Mailing Address—Street/PO Box,City,State,ZIP Code 2.Property Owner Area Code+Telephone Number = z Sam&Jodi Fisher 0; 4017 STH 73 s: Deerfield,WI 53531 it p 3.Property Owner E-Mail Address oz sam.fisher @Iakemilis.k12.wi.us a 4.Highway Number(s) 5.County • 6. ❑City❑Village El Town 7.Side of the Highway —• 73 Dane of:Deerfield ❑North ❑South ❑East ®West c of 8.Located within the 9.Fire or Street Number(If applicable) 0 r , z a SE Quarter,of the SE Quarter,Section 16,Town 7 North,Range 12E 4017 O▪ 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the o z_' 275 Ft. North nearest non-side road connection 1200 Ft. Jima Lane on the same highway? (Feet or Nines) (N.S.F,WJ (Foot or Miles) U• Log Mile or Reference Point(Completed by WisDOT): RP=020+0.21 w 12.Proposed Activity 13.Proposed Use(Check one) 16.Proposed Trips Per Day(Check one) IL F,o (Check one) ❑Urban—Commercial/Industrial ❑Rural—Agricultural 0 Seasonal ❑101-1000 o ❑Construct New ❑Urban—Residential ❑Public Road ❑1-50 ❑Over 1000 ✓ ❑Attar Existing ❑Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 at 10 Rural—Residential Peak hour traffic count: z❑ Remove Existing Y Is this a change of the existing use(If applicable)? ❑Yes in No o ®Document Existing V 14.Proposed Width: 24 115.Proposed Surface: gravel 17. El Yes ❑No Is the property zoned? Include documentation from the jurisdictional zoning authority. 18. Explain how thedandis 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 El No Does the property abut or border another public road? If yes, provide the road's name. 23. El 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. 0712-164-9560-9 Identification Number ❑ Temporary. Expiration date: SEE BACK PAGE FOR ❑ This voids/replaces permit number. CONDITIONS OF ISSUANCE 13-7-09 ❑ Shared Co-user name: connection Related ID number. X L��7 ' � 3/11/09 (WisDOT Authorized Representative) (Date) File: (If Computer-filled,Brush Script Font)