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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(VVisDOT) DT1504 9/2009 s.86.07(2)Wis.Stats.&Ch.Trans 231 Wis.Adm.Code • This form is an application for permission for a STH Connection. If approved,the Document Identification Number: permit does not create a right of access or access easement for the property. W 13-100214807-2016 • If the property has any legal restrictions that prohibit access to a state trunk highway . (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 H 2 this form per the instructions. One form is required per connection. For more 0 LL SW Region-Madison Office information,visit: http://wisconsindot.qov/Paqes/doinq-bus/real- to z 2101 Wright St. estate/permits/default.aspx 3 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 Tim Dahl Blaine&Lisa Haugen Pi 2 N4321 Poplar Ave. 1562 Thoreau Drive ti Cambridge,WI 53523 Sun Prairie,WI 53590 a_ a. 0 Q 3. If Not Property Owner,Reason for Application Builder 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway r.• 73 Dane of: Deerfield ❑ North ❑ South ® East ❑West a O O 8.Located within the 9.Fire or Street Number(If applicable) J F z g SE Quarter, of the NE Quarter, Section 21,Town 7 North, Range 12 East o F= 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11. How far is the location from the o u. nearest non-side road connection across North Street 150 ft North on the same highway? street z o (Feet or Miles) (N,S,E,W) (Feet or Miles) t) Log Mile or Reference Point(Filled in by WisDOT): RP=019+0.37 w 12. Proposed Activity 13.Proposed Use(Check one—See instructions for category description) 16.Proposed Trips Per Day(Check one) H 0 (Check one) ❑ Urban—Commercial/Industrial I] Rural—Agricultural ❑ Seasonal ❑ 101-1000 z ❑ Urban—Residential El Public Road ® 1-50 ❑ Over 1000 Construct New r.• 2 ❑ Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑ 51-100 o ❑Alter Existing w p ❑ Rural—Residential z = ❑ Remove Existing Peak hour traffic count: Is this a change of the existing use(If applicable)? ®Yes ❑ No o ❑ Permit Existing ✓ 14.Proposed Width:24 ft 115. Proposed Surface:gravel 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. n _,A It is further understood that WisDOT's approval is subject to applicant's full X /Litt Dait 8/29/2016 compliance with relevant state statutes and administrative rules, plus any laws, codes, rules, regulations, ordinances and permit requirements of (Property Owner or Authorized Representative) (Date) other jurisdictional agencies.The alteration of this form by the applicant is prohibited.Under s.86.073 Wisconsin Statutes,WisDOT's permit denial or 608-220-2100 dahl25 @charter.net revocation may be appealed. (Area Code and Telephone#) (E-mail address if available) FOR OFFICIAL WISDOT USE ONLY—DO NOT WRITE BELOW THIS LINE ❑THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ® Permit APPROVED(THIS PERMIT IS REVOCABLE) ❑ Permit DENIED ❑ Application DISMISSED X /X1 09/02/2016 (Wis DOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font) ❑Temporary permit. Expiration date: ❑This permit voids/replaces permit# ® Shared Co-user name: FJD Farm LLC connection Related permit#