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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) _ DT1504 6/2006 s.86.07(2)Wis.Stats.&Ch.Trans 231 Wis.Adm.Code - • This form is NOT an application for, and if approved the permit does NOT create, a RIGHT OF ACCESS or ACCESS EASEMENT for the property. z • If the property has any legal restrictions that prohibit access to a state trunk highway LL °- . (STH),WisDOT cannot approve an STH connection permit for the property. O < • Please type or print neatly in ink. Fill out the required information on both sides O o of this form per the instructions. One form is required per connection. For more o z information,visit: www.dot.wisconsin.gov/business/rules/property-permits.htm § • 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) I- z f'�iA :e/ l-l �e!/2 z -- 76a 3 Wy 73 7.a. o /liO 5Ical/ Cvj S35S�( Q z 3.If Not Property Owner, Reason for Application z 4.Highway Number(s) 5.County 6. ❑ City El Village JJ Town 7.Side of the Highway 0 a 73 Q r-9 e of: York ❑ North ❑South ❑ East (West z -- -- :t��4.1_•.at .G1't(It11t7000(:�.<S."oi €i ` �aloard7 ra:leg I'Ieel wasf __ _—_Z.. ic-E-@uarter-ofthe e-Quarter;section- -7Towrr • -North;Rarrge- o Ix - 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11. How far is the location from the z z ` / �-7' �f c , F� nearest non-side road connection 3O0 z COlt rl ty /--/W y V �`� J0� on the same highway? 1---74 o (Feet or Miles) (NOE,W) (Feet or Miles) Log Mile or Reference Point(Filled in by WisDOT): k P= o3d?..f- a, 34 u, 12. Proposed Activity 13.Proposed Use(Check one-See instructions for category description) 16.Proposed Trips Per Day(Check one) a_ z (Check one) 1... 0 ❑ Urban-CommerciaVIndustrial ❑ Rural-Agricultural ❑ Seasonal ❑ 101-1000 o a ❑Construct New ❑ Urban-Residential El Public Road al 1-50 ❑ Over 1000 o 2 (�Alter Existing ❑ Rural-Commercial/Industrial ❑Trail or Trail Crossing ❑ 51-100 ® Rural-Residential Z Z LI Remove Existing Is this a change of the existing use(If applicable)? ®Yes ❑ No Peak hour traffic count: o — ❑ Permit Existing V 14. Width:Pro Proposed p Ffi 15.Proposed Surface: 1044 4tAye/ 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. ,/ _ �/ It is further understood that WisDOT's approval is subject to applicant's full X ‘,,,„,_,t, f ``/Z� / 0 compliance with relevant state statutes and administrative rules, plus any Owner or Authorized R sentative (Date) laws, codes, rules, regulations, ordinances and permit requirements of (Property ) ) other jurisdictional agencies. The alteration of this form by the applicant is ( omputer filled,Brush Script Font) prohibited. Under s. 86.073 Wisconsin Statutes, WisDOTs permit denial 720) w.3.. ! 1/L I Cpl()9.20 35a acY'r or revocation may be appealed. -rea Code and Telephone#) (E-mail address if available) FOR OFFICIAL WISDOT USE ONLY-DO NOT WRITE BELOW THIS LINE I 'THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ❑ PERMIT DENIED See attached letter for details (, Reeta-CL Q.-y:51,1 u(i r+ tn1 t1 - ' PERMIT APPROVED Permit Number Q I g ', M�A;M-4r C v'itr,� (A -Iwo THIS PERMIT IS REVOCABLE l3—( 6---6° U -1J. t�1��l(S. 1 X ' ` • j 1 6.e fyl,n t iiv" (WisDOT Authorized Representative) (Date) S�f�Q 5 l� S 5 (If Computer-filled, Brush Script Font) (p , f- ❑Temporary permit. Expiration date: ❑This permit voids/replaces permit# ❑ Shared Co-user name: connection Related permit# File: