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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WIsDOT) DT1504 4/2009 s.86.07(2)Wis.Stats.&Ch.Trans 231 Wis.Mm.Code • This form is an application for permission far a STH Connection.If approved,the w ooa,mem Identmeation Number 13-9-09 permit does not create a right of access or access easement for the property. 2 z • If the property has any legal restrictions that prohibit access to a state trunk highway t• (STH),WisDOT cannot approve a STH connection permit for the property. Wisconsin DOT 0 • Please type or print neatly in Ink.Fill out the required information on both sides p o SW Region-Madison Office of this form per the instructions.One form is required per connection. For more w z 2101 Wright St. information,visit www.dot.wisconsin.00v/business/rules/property-permits.htm g 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) John 0 Morschauser Jerry&Jane Krueger 0 1354 Burve Rd 75 Isadore St a i Deerfield,WI 53531 West Haven,CT 06516 s: J a.;0. a. O. az: 3.If Not Property Owner,Reason for Application Build new home z r 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway O !' 73 Dane of:York ❑ North ❑South ❑ East ®West 0 0 8.Located within the 9.Fire or Street Number(if applicable) ;z g SE Quarter,of the SE Quarter,Section 27,Town 9 North,Range 12E o. ; F.„. 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 CTH"TV" 90 ft North 210 ft • on the same highway? o (Feel or Miles) (N,SSE,W) (Feet or Mee) Log Mile or Reference Point(Filled in by WisDOTj RP=035+0.017 ; w 12. Proposed Activity 13.Proposed Use(Check one—See instructions for category description) 16.Proposed Trips Per Day(Check one) (Check o( one)) ❑Urban—Commercial/Industrial ❑ Rural—Agricultural ❑Seasonal ❑ 101-1000 z t-: ❑ Urban—Residential ❑Public Road ® 1-50 ❑Over 1000 o d: ❑Construct New .,S ❑ Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 a rC ❑Alter Existing w o El Rural—Residential z;1 : ❑Remove Existing Peak hour traffic count: Is this a change of the existing use(If applicable)? ❑Yes ®No o ®Permit Existing O 14.Proposed Width:24 ft 1 Wi 15.Proposed Surface:gravel QUESTIONS 17-27 on BACK PAGE All connections have restrictions,which include the information preprinted The applicant affirms that all information provided on and submitted and filled-in on this application along with any conditions, covenants, into this form Is correct and complete. denial incorrect s supplemental provisions,superimposed notes, and detail drawings added well as criminal Information prosecution man under In permit d scot si revocation as by WisDOT. The applicant shall be responsible for complying with these well as criminal prosectrtion under s.946.32 Wisconsin Statutes. restrictions along with the construction and maintenance of the connection. /i It is further understood that WsDOTs approval is subject to applicant's full X d %�e�uui 05-13-09 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 (If Computer-filled,Brush Script Font) other jurisdictional agencies.The alteration of this form by the applicant is prohibited.Under s.86.073 Wisconsin Statutes,WisDOT's permit denial or 608-764-5025 jmorsch @hotmail.com revocation may be appealed. (Area Code and Telephone#) (E-mail address If available) FOR OFFICIAL WISDOT USE ONLY—DO NOT WRITE BELOW THIS LINE _i El THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ® Permit APPROVED(THIS PERMIT IS REVOCABLE) 1.This driveway does not meet spacing requirements,but it is an ❑ Permit DENIED exception to WisDOT policy because it was previously permitted. ❑ Application DISMISSED X 5/26/09 (WisDOT Au orized Representat (Date) (If Computer-filled,Brush Script Font) ❑Temporary permit.Expiration date: ®This permit voids/replaces permit# 13-1945-04 ❑ Shared Co-user name: connection Related permit#