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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 type,configuration,drainage,etc.,for a property in which WisDOT authorized an LL o Wisconsin DOT access point under a previous s.84.25,Wis.Stats.project. 8 a SW Region-Madison Office • Use only one DT2234 form for each connection. When work in the highway right-of- 0 o 2101 Wright St. way is also needed,use form DT1812 together with form DT2234. 0 u. • Please include a copy z Madison,WI 53704 py 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 II z John P.&Sandra L.Ziegler 608 835-3019 ° 824 Dunn Avenue o a Oregon,WI 53575 re re a• o 3.Property Owner E-Mail Address O z jpz93@aol.com a O 4.Highway Number(s) 5.County 6. ❑City ❑Village ®Town 7.Side of the Highway a 14 Dane of:Rutland ® North ❑ South 0 East 0 West z O 0 8.Located within the 9.Fire or Street Number(If applicable) J P z *4 NE Quarter,of the NW Quarter,Section 7,Town 5 North, Range 10 East 1256 o z t— 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the UZ Oft— z Hill Road 1,625 ft North nearest non-side road connection across hwy the same highway? wy o (Feet or Miles) (N,S,E,W) (Feet or Miles) Log Mile or Reference Point(Completed by WisDOT): Log mile=56.38 i 12. Proposed Activity 13.Proposed Use(Check one) 16.Proposed Trips Per Day(Check one) �. z (Check one) I- o ❑ Urban—Commercial/Industrial ❑ Rural—Agricultural ❑ Seasonal z a ❑ Urban—Residential ❑ Public Road ❑Over 1000 ❑Construct New ® 1-50 ❑Over 1000 w o ❑Alter Existing ❑ Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑51-100 ® Rural—Residential z z ❑ Remove Existing Peak hour traffic count: V — II Document Existing Is this a change of the existing use(If applicable)? ❑Yes Z 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 /Storage Shed 19. ®Yes ❑No Does the property owner have any plans to change the zoning or land use for the property? If yes,explain. LC1 to RH2 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. 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. 052/0510-072-8230-9 ❑ Temporary. Expiration date: SEE BACK PAGE FOR identification Number ❑ This voids/replaces permit number: CONDITIONS OF ISSUANCE 13-100246328-2018 ❑ Shared Co-user name: �� connection Related ID number: X 01/03/2018 File: (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font)