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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 W z type, configuration,drainage,etc.,for a property in which WisDOT authorized an IT o Wisconsin DOT access point under a previous s.84.25,Wis. Stats. project. SW Region Madison Office • Use only one DT2234 form for each connection. When work in the highway right-of- o 0 2101 Wright St. way is also needed, use form DT1812 together with form DT2234. u, z LL 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 ce z z Don Squire Jr. 608-770-1800 33 ° 2046 Norgaren Road a Stoughton,WI 53589 w o 3.Property Owner E-Mail Address a a O ? a 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway o• 51 Dane of: Dunkirk ® North ❑South ❑ East ❑West a o 0 8.Located within the 9.Fire or Street Number(If applicable) J I z - a SW Quarter,of the SW Quarter, Section 02,Town 05 North, Range 11 o x • 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 z z — Pleasant Hil Road 625 feet East on the same highway? 85 feet o (Feet or Miles) (N,S,E,W) (Feet or Miles) U Log Mile or Reference Point(Completed by WisDOT): RP=042+0.88 w 12. Proposed Activity 13.Proposed Use(Check one) 16.Proposed Trips Per Day(Check one) (Check one) o 111 Urban—Commercial/Industrial ❑ Rural—Agricultural ® Seasonal 12 101-1000 z ❑ Urban—Residential ❑ Public Road ❑ 1-50 ❑ Over 1000 o Construct New ® Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑ 51-100 • ®Alter Existing ❑ Rural—Residential Z z ❑ Remove Existing Peak hour traffic count: 2 g Is this a change of the existing use(If applicable)? ®Yes ❑ No o — ❑ Document Existing - U 14.Proposed Width: 21.5' 15.Proposed Surface: Gravel 17. ®Yes ❑ No Is the property zoned? Include documentation from the jurisdictional zoning authority. 18. Explain how the land is currently being used: Agricultural 19. ®Yes ❑ No Does the property owner have any plans to change the zoning or land use for the property? If yes,explain. Just a small area for a wireless communications site 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. Pleasant Hill Road 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: 026/0511-023-9001-1 ❑ Temporary. Expiration date: Identification Number SEE BACK PAGE FOR ❑ This voids/replaces permit number: CONDITIONS OF ISSUANCE 13-100214248 4016 ® Shared Co-user name: Central States Tower III,LLC connection Related ID number: N/A (Lessee) X 08/24/2016 File: (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font)