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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) DT1504 9/2009 s.86.07(2)Wis.Stats.&Ch.Trans 231 W_ is.Ad-n.Code • This form Is an application for permission for a STH Connection.If approved,the Document Identification Number. 13-100231627-2017 permit does not create a right of access or access easement for the property. • If the property has any legal restrictions that prohibit access to a state trunk highway Li Z Wisconsin DOT (STH),WisDOT cannot approve a STH connection permit for the property. O SW Region-Madison Office • Please type or print neatly in ink.Fill out the required information on both sides of t— g this form per the instructions.One form is required per connection.For more a o 2101 Wright St. information,visit httaa/wisconsindot,gov/Pages/doinq;busheal- N z Madison,WI 53704 estate/permits/default.aspx • 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) Dale and Karen Stenjem I-. 0 3012 State Hwy 134 P Cambridge WI 53523 42 a. a z 3.If Not Property Owner,Reason for Application 4.Highway Number(s) 5.County 6. ❑City 0 Village ®Town 7.Side of the Highway r.a• 134 Dane of:Christiana ❑ North ❑South ®East ❑West 0 8.Located within the 9.Fire or Street Number(If applicable) _ NW Quarter,of the NE Quarter, Section 1-6,Town b North, Range 12 E 3144 o � 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the tu z nearest non-side road connection z - State Farm Road 230 ft. South on the same highway? 1/4 mile+ ✓ (Feet or MINN (N.8 E.WI (Feet or MNes) 92..- OOt F1 -�o. Log Mile or Reference Point(Filled in by MOOT):MOOT): RP - d 12. Proposed Activity 13.Proposed Use(Check one—See instructions Rural�—Agricultural description) O SeasonalTr❑s101r 000(Check one) � _ (Check one) o ❑Urban Commercial/Industrial z ❑Construct New ❑ Urban-Residential 0 Public Road 0 1-50 ❑Over 1000 o ❑Alter ost Construct New ❑Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 Z u 0 Rural-Residential z z ❑Remove Existing Peak hour traffic count 5 1— ®Permit Existing Is this a change of the existing use(If appilcable)7 0 Yes ®No 14.Proposed Width:existing 115.Proposed Surface:existing gravel QUESTIONS 17-27 on BACK PAGE AN connections have restrictions,which include the Information preprinted The applicant affirms that all information provided on and submitted with and filled-in on this application along with any conditions, covenants, incomplete this form in o Is correct and complete. denial or incorrect as or supplemental provisions, superimposed notes,and detail drawings added incomplete inal pros may result In permit denial in revocation as by Wis00T. The applicant shall be responsible for complying with these well as criminal pros_cution under s.948.32 Wisconsin Statutes. restrictions along with the construction and maintenance of the connection. It is further understood that WisDOTs approval is subject to applicant's full X r.. r, 6/20/17 compliance with relevant state statutes and administrative rules plus any laws, codes, rules, regulations, ordinances and permit requirements of (Prop rty Owner or Author epresentetive) (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 608-423-4715 Tstenj@gmail.com revocation may be appealed. (Area Code and Telephone# i p #) (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 � ` �l� 'went (� ( te) (1Afis OT Aut prized resentativ� ( te) (If Computer-filled,Brush Script Font) ❑Temporary permit.Expiration date: ❑This permit voids/replaces permit# ❑ Shared Co-user name: