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DOCUMENTATION OF AUTHORIZED CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) DT2234 6/2006 s.8425 Wis.Stats. • This form is NOT a permit. It serves to document an STH connection regarding its w 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. 6 a SW Region-Madison Office • Use only one DT2234 form for each connection. When work in the highway right-of- p a 2101 Wright St. way is also needed, use form DT1812 together with form DT2234. ° z Madison,WI 53704 • Please include a copy of the property deed. 3— w 1.Property Owner Name and Mailing Address—Street/PO Box,City,State,ZIP Code 2. Property Owner Area Code+Telephone Number = z John P.&Sandra L.Zegler 608 455-1616 3 0- W1449 Alpine Road a Brooklyn,WI 53521 re cg a 3_Property Owner E-Mail Address O z jpz93 @aol.com a O 4. Highway Number(s) 5.County 6. ❑ City ❑Village E Town 7.Side of the Highway 14 •Dane of: Rutland ❑North ❑South E East ❑West 0 0 8.Located within the 9. Fire or Street Number(If applicable) 't a z < SE Quarter,of the NW Quarter,Section 7, Town 5 North,Range 10 East 1256 o z P 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the la ? nearest non-side road connection directly Hill Road 1,630 ft West on the same highway? across hwy o o (Feet or Kies) (N,S,E.W)_ (Feet or Mies) Log Mile or Reference Point(Completed by WisDOT): RP=217E+0.31 W 12. Proposed Activity 13.Proposed Use(Check one) 16.Proposed Trips Per Da y(Check one)(Check one) El I— o Urban—Commercial/Industrial ❑ Rural—Agricultural ❑ Seasonal ❑ 101-1000 z a ❑ Urban—Residential ❑ Public Road 1-50 o▪ a ❑Construct New ® CI Over 1000 El❑Alter Existing Rural—Commercial/Industrial ❑ Trail or Trail Crossing ❑ 51-100 i o ® Rural—Residential z z z ❑ Remove Existing Peak hour traffic count: V — ® Document Existing Is this a change of the existing use(If applicable)? 0 Yes ❑No 14.Proposed Width: N/A 115.Proposed Surface: N/A 17. ®Yes ❑ No Is the property zoned? Include documentation from the jurisdictional zoning authority. 18. Explain how the land is currently being used: Residential/Ag with a home and storage shed 19. E Yes ❑ No Does the property owner have any plans to change the zoning or land use for the property? If yes,explain. Change from RH-1 to LC-1 (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. ®Yes ❑No Are there any existing connections serving the property? If yes,how many? 1 24. E 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 El 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. 052/0510-072-8230-9 ❑ Temporary. Expiration date: SEE BACK PAGE FOR Identification Number ❑ This voids 1 replaces permit number: CONDf17ONS OF ISSUANCE 13-100223687-2017 ❑ Shared Co-user name: connection Related ID number. X 02/22/2017 File: (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font) £•d JelbeIZ e0Z:90`L I. £Z cle