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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 LI type, configuration, drainage,etc.,for a property in which WisDOT authorized art LL o Wisconsin DOT access point under a previous s.84.25,Wis.Stats. project. 8 a SW Region Madison Office E • 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. z u. Madison,WI 53704 • Please include a copy of the property deed. re 1.Property Owner Name and Mailing Address—Street/PO Box,City,State,ZIP Code 2.Property Owner Area Code+Telephone Number z Theran Kahl 608 577-7651 2 1172 Maple Grove Road 0. a Stoughton,WI 53589 re o rd 3.Property Owner E-Mail Address o 1'- kahlt @hotmail.com re Z 4.Highway Number(s) 5.County 6. ❑City ❑Village Z Town 7.Side of the Highway 51 Dane of:Albion ❑ North ❑South ❑ East ❑West a 0 0 8.Located within the 9.Fire or Street Number(If applicable) J F z a SE Quarter,of the SW Quarter,Section 5,Town 5 North, Range 12 East o.c 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 CTH"W" 2,060 ft West on the same highway? 170 ft o (Feet or Miles) (N,S,E,W) (Feet or Miles) C). Log Mile or Reference:Point(Completed by WisDOT):- _-Log Mile=33.53 m- 12. Proposed Activity 13.Proposed Use(Check one) 16. Proposed Trips Per Day(Check one) a. z (Check one) I-, o ❑ Urban—Commercial/Industrial CI Rural—Agricultural I:Seasonal ❑ 101-1000 z ❑ Urban—Residential ❑ Public Road Z 1-50 ❑ Over 1000 o ❑Construct New ❑ Rural—Commercial/Industrial ❑Trail or Trail Crossing ❑ 51-100 u re ❑Alter Existing Z Rural—Residential z o ❑ Remove Existing Peak hour traffic count: z z Is this a change of the existing use(If applicable)? ❑Yes ❑ No o- Z Document Existing - 14.Proposed Width: 16 ft 15. Proposed Surface: Gravel 17. Z Yes ❑No Is the property zoned? Include documentation from the jurisdictional zoning authority. 18. Explain how the land is currently being used: Vacant wooded lot 19. ❑Yes Z No Does the property owner have any plans to change the zoning or land use for the property? If yes,explain. Note:Items 20 and 21 purposely omitted 22. ❑Yes Z 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. Z 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 Z 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: 0512-053-9700-7 ❑ Temporary. Expiration date: -SEE BACK PAGE FOR Identification Number ❑ This voids/replaces permit number: CONDITIONS OF ISSUANCE 13-100247967-2018 ❑ Shared Co-user name: connection Related ID number: X / ~�% 02/07/2018 File: (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font)