HomeMy WebLinkAbout020-1300-10-000 r
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner Lv
Property Address ! 41--
City/State d cO,0 't c Wx- kiD
Legal Description:
Lot I-rd Block -- Subdivision/CSM #
%4„9,&[ V4, Sec. /Z, 1MN -RJ?W, Town of 6 GUA k PIN # 0, —,,1 --/O
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer _� ize ST/PC / / - Setback from: House [, Well >.�'d P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Servic Vent to fresh air ' Water Line
Meter location
Alarm loca 'on
SOIL ABSORPTION SYSTEM /G`r
r
Type of system: 4 1CO Width Length 5 Number of Trenches z
Setback from: House yr Well >, ► P/L Vent to fresh air intake > ys '
ELEVATIONS
t� �
Description of benchmark 76b Ors �za IZE?r ' — ar- /.3/ Elevation
Description of alternate bent nark 4a )C�rcer) riE^x, T — 407 - #/06 Elevation X02•
Building Sewer 1. d ST/HT Inlet /o0 72 _ ST Outlet PC Inlet
PC Bottom Header/Manifold F9, 76 Top of ST/PC Manhole Cover A0 .2
Distribution Lines
Bottom of System
Final Grade O ^�' 4 O ( )
Date of installation// / / Permit nu ber State plan number
Plumber's signature .r— License number le Date / / / ,V/Pf
Inspector _ Z g%/. rAo/
Complete plot plan �
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NOTICE Please rovide the following:
P
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
30 '
PLAN VIEW
a = BM
t.,&
� 1X S - o
3s'
7 y0 r
H
INDICATE NORT
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Wisconsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT S , r- te a., r K
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: __
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. S T . CR 1X
Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan o.:
WERT, DARREL HIUDSON
CST BM Elev.:- Insp. BM Elev.: r M Description: Parcel Tax No.:
�•b' .� .. , ..
TANK INFORMATION ELEVATION DATA A9900117
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic i Benchmark 5Z of, 5'L �•O'
Dosing 0.66 luS.a$,
Aeration Bldg. Sewer 1 / 0
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I to ntake ROAD
ir
Septic B -2 NA
Dosing I Z NA Header/ Man.
Aeration NA Dist. Pipe v� 6o,,�8
Holding - e,n o Q� I q
PUMP/ SIPHON INFORMATION P'R;4Gr2 ce- �• �'Z- �(�• SlD
Man cturer 102, Zz
Model Number GPM
TDH Lift F . .on System Ft
oss Fi
Fw4eM5 Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
ED T Width f Len th / No. T"el+es PIT No. Of Pits Inside Dia. Liquid Depth
EN I N 2 DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION TypeO ) CHAMBER �-5� -� T Mode Number: > OR System: '
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s), u / � y x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. Length Dia. Spacing (� 7 5'S z
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes El No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
uO��i C I'ON .' TTT T S T 7 Ah 1 1 71 Y n ST. ♦ A /\I K-VV DR31VE
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ll— Io- CO 1
Plan revision required? ❑ Yes 0 No _
Use other side for additional information. I I h o l i d L
SBD -6710 (R.3/97) Date Inspector's Signature Cert No
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ADDITIONAL COMMENTS AND SKETCH `
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
PERMIT APPLICATION Ave
1 4.4consi n SANITARY ERM A O 201 E. Washm on Ave In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary PerTit Number
The information y ou p rovide may be used b other government agency programs 33 p
y p y y g g y p g El if revision to prevlou plication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
— ov W a 1/4, S Q T N, R /4 E (o rev
Property O ner's Mailing Address Lot Number Block Number
f ffo !' ,CV,� /3 0
City, State Zip Code Phone Number Subdivision Name oFE�SMh# amber— �y
Awn
AA
Gut
II. TY F BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF /S�dCe 1. ,R/ftt 4y WW
III. BUILDIN USE: (if building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on A. Check box on line B, if applicable)
A) 1. New 2_ F] Replacement 3. E] Replacement of 4_ ❑ Reconnection of 5. E] Repair of an
- _____System System _____________ Tank Only______________ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 9seepage Bed 21 E] Mound 30 [] Specify Type 41 [] Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill AT t6p
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min/inch) , Elevation
,S'U �. Feet l ol, ,o Feet
Capacit
VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper
INFORMATION g Gallons an Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
epti or�ik ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 1 ❑ 1 ❑ ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of th onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stam #WMPRSW No.: Business Phone Number:
zi2g 7
P u ber's Address (Street, ity, SXalteK C de):
IX. COUNTY /nFPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssued Issuing Adent Signature (No Stamps)
ISA roved v/ 1 / S urcharge Fee) / I
pp []Owner Given Initial 00 ) Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -W99 (K 11/96) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS 1
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
DAVE FOGER'Y PLUMBING
Licensed Perk Tester & Plumber
1132 p
Foogg�ee�rty H� 8d
R0BERk WIS� 361N
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Wiscc6p4in Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of 3
Bureau of•Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and ( ov
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
-a —
APPLICANT INFORMATION - Please print all information. ?M D to
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
�G l �--- Govt. Lot �- 1 /4s� 1/4,S T �9 ,N,R E (4
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
�Od '=� ST • /3o vrc
City State Zip Code Phone Number City ❑ village Town Nearest Road
-!LO ,q f) I wx I 51ye 6 1 (79 ) 11 GG 14 0 0o v r
lei New Construction Use: Residential / Number of bedrooms Addition to existing building
b Replacement ❑ Public or commercial - Describe:
Code derived daily flow _A& _ gpd Recommended design loading rate y 7 bed, gpd /f1 gpd /ft
Absorption area required trf bed, ft 2 �.s_? trench, ft Maximum design loading rate bed, gpd /ft r trench, gpd /ft
Recommended infiltration surface elevation(s) ��•� ft (as referred to site plan benchmark)
Additional design /site considerations /rlai(//c-
Parent material Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U 4S ❑ U OS ❑ U W1 S ❑ U ❑ s 0 U ❑ S U
SOIL DESCRIPTION REPORT
Boren # Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground 3 _ ld? L j
elev.
Il S L
Depth to
limiting
factor
in.
Remarks:
Boring #
45
Z
Ground
elev.
10
Depth to
limiting
factor
>!�_in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
kir / I f- 2� .f0
PROPERTY OWNER 244 _ SOIL DESCRIPTION REPORT Page Z of `
PARCEL I.D.# ®->O - 3cJ — l4
Boren # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3
0-17 Z dr—� // Fs
4 S
Ground
elev.
Depth to
limiting
factor
>�Lin.
�3
v
Remarks:
Boring #
A SmAC oW 11
, V z - - M
Ground
elev.
��ft• '
Depth to 0•
limiting
factor -lit v
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # O —� .9 FS Fie
IF5 4evic)e s r .7 ;.
RuL s —
Ground
elev.
Depth to
limiting
factor
7Z4F in. Remarks:
Boring #
i3
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
SBD -8330 (R. 07/96)
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Li Perk Tester & Plumber
Fcc�eer�ty Hoottss Road
ROBERPhone , 49-36 N
407 /06
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- ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer "P",/
Mailing Address 7� fs 5 Y4! f
Property Address ��6 frnol wood g)/L
(Verification required from Planning Department for new construction)
City /State 94(/X� _ gr4l-r— Parcel Identification Number
LEGAL DESCRIPTION
Property Location� ' ' /., ' / <, Sec. 1Z TAN -R�W, Town of l
Subdivision ���� �i ° e�J " � ��� e / , Lot # /.3e .
Certified Survey Map # , Volume , Page #
Warranty Deed # 4 /S` , V 7 Volume Pw/ d , Page #
Spec house ❑ yes � no Lot lines identifiable ' 0 yes ❑ no
SYSTEM MAINTENANCE
Improper use.and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
SIGNATUP4 OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATUREOF APPLICANT DATE
* * * * ** Any information that is mis- representedmay result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
1
t
DOCUMENT NO WARRAWff DID TH IS SPACe otseRV,D , Oa acCOao DATA
STATE BAR Of WISCONSIN FORK ! — IM
m REGISTER'S offiCE �t
Edna G. Smith, aA /a Edna Smith, a single r.C, CO d
I.
_
... ....... ..............................._....._ . -.. -.
.................-........ ..........-- •- ........... ! I
....................... ............................... d JAN 0 41C. 0
............... ................... .. ... ... .......................
10:40 M i
conveys and warrants to ... par re.1.Wert....a/)t /a..Da
......... ..lert,....and, Beverly - Wer.t & .. a/k /_a .Beverly..- A........ I .a
. Marts.-- .hus.band...and .wife.. as .. tenants --- i.n .............. `, �`" ►�
...common. and..nat..as_jo ' nt..- tenants ..................I......... +
........................... .. ............. ......... . ... ........... -
.. .. .. ..... .. .... ........................ .. ..........__.. ........ ....._ ... ............ RETURN TO Gwin & Gwin
.. . .. :I
........................ j. P . . Bo 1
..................... . ....
... _........._ ............ ..... I� Hudson, WI 54016;
- ....... .
the following described real estate in ........... St olX ..........
County,
:hate of Wisconsin:
Tax Parcel No:
.............................. it
(See legal description on reverse side)
�i
TRANSE tali I!
This is.- no.t.__.. homestead prop
_
i •---•-- - P Pe Y-
(yd (is not)
Exception to warranties:
I,
i Dated this ............ _ ......... ........... ........ day of _...........January._. 90
... ............ (SEAL) (SEAL)
. . ....... .. .................. ..---- .............. -- . ...... . • .,Edna . G.. Smith ... -..
_ ----- ....._....._ ...... ................ ...........(SEAL) _ _. _ (SEAI.1
I • t-e /
_ .... .. ..... ........_......_...... -.... ...._..
AUTHRNTICATION ACHN0WLED('r31 - pWT �v
Signature(s) ............................................................ . STATE OF WISCONSIN l
ss _
............. ...............................
. St. Croix
..--- .- County. •��.. ,,,
authenticated this .__. ...da y of ..................... ....., 19...... Personally came before me this ----- --------- . day of
.
- --N/A .......__ --
January.__.- .. - -.._, 19. 90__ the above named
Edna..G- ...Smith, a /k /a Edna Smith,
• a - single woman
- --
TITLE: MEMBER STATE BAR OF WISCONSIN
.... - - - - --- _ (If not, ...........
authorized by 706.06, Wis. Stats.) to me known to be the person ....•.. - who exccwtcd the
fereg II. ,n5tru t tend acknnowl the <anle.
T•4:S INSTRUMENT WAS DRAFTED PY A�� —s.� •` J /' 1 Ems_
..Atty..... )iug;� -. H. -. Gwin -+. - Gwin_ & - -- . r , ,
ond- _St ._,_ Hgdson,.._Wl 54016 lV * otnry Public St._ Croix count, W;,.
(Signatures may be authenticated or acknoaird;;ed. Both My ('emmissinn is �p i. (Ii not, slate ern` ratio+
are not necessary.) date: 19)?/ .
•Na ft of pr7wm eienise in any cagarita• xhoo',t be type r 10-1 I -1 ". th- it
' f
a
A parcel of land located In the Northwest Quarter of the
Southeast Quarter (NW1 /4 of SE1 /4), the Southwest Quarter of
the Southeast Quarter (SW1 /4 of SE1 /4), the Southeast
Quarter of the Southwest Quarter (SE1 /4 of SW1 /4), the
Southwest Quarter of the Southwest Quarter (SW1 /4 of Sill /4),
the Northwest Quarter of the Southwest Quarter (NW1 /4 of
SW1 /4), and the Northeast Quarter of th@ Southwest Quarter
(NE1 /4 of SW1 /4) of Section Seventeen (17), Township
Twenty -nine (29) North, Range Nineteen (19) West, in the
Town of Hudson, described as follows: Commencing at the
East Quarter (E1 /4) corner of said Section 17, thence
Westerly along the East -West Quarter Section Line S 89 18'
41" W, 1,332.98 feet (previously recorded as N 89 53' 20"
W, true beaging, 1,332.90 feet), to the point of beginning;
thence S 00 03' 03" W, 1,747.21 feet (previously recorded
as S 0 05' 20" W ,734.97 feet) more or less to a point
which is also N 00 03' 03" E, 880.11 (recorde$ as 880) feet
from the South Lire of Section 17; thence S 89 09' 27" W
(recorded as S 88 59' 10" W) and parallel to said South
Line of Section 17, 2,983.50 feet more or less to a point
which is also on the East line of the Plat of Trout Brook
Woods; thence Northerlg along said East line of the Plat of
Trout Brook Woods, N 0 41' W, 827.32 feet; thence N 0 36'
40" W, 924.65 more or less to the East -West Quarter Section
Line of Section 17; thence Easterly along said East -West
Quarter Section Line, 3,006 feet more or less to the point
of beginning.
This Warranty Deed is given to correct the legal description
In two prior deeds between the same parties, the first dated
February 20, 1978 and recorded February 23, 1978 in Vol.
569, at Page 612, as Document No. 346777, and the second
dated August 30, 1984 and recorded September 5, 1984 in
Vo1.695, at Page 565, as Document No. 396063, all in the
Office of the Register of Deeds for St. Croix County,
Wisconsin.
This transfer is exempt from a transfer fee pursuant Section
77.25(3) of the Wisconsin Statutes.
I
I PAGE 182 I g-gj.
VdW
DLA r S
I
PSI �
I Regb�er
208.24'
O I
3 a
O I m In 0 ro
LOT 133 " oN 8 10
1
m 1.60 ACRES O g
69,694 SQ. FT. Z
(N89 'E 150.00')
S 88 ° 48' 30 "W
149.79 I
9
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,L2� N.. 616' CV I Q
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LOT 132 LOT 130 M �; of 01
�-
1.06 ACRES N rn 1.07 ACRES �I QI I
46,086 SQ. FT. M 46,565 SQ. FT. M 106 QI Q�I �i
po �-I Q1
3 No QI
N � _
N88 ° 56`55 "E 253.02' Z V I (]
o (N89 ° 15'14 "E 150.0d) 33' 33'
1 1 LOT 131 N Z S8 4 z
1.00 ACRES O / _ \
n 43,747 SQ. FT. i' � � _ _ \
\ � BROOKWOOD
° 0 S88 ° 46'46 "W
154.80'_ ..
�/ �o 2� 6 '• 4 (CHORD ON CURVE
�� �- �� RECORDED AS S27
r � •� qa, cp ,� o o �.� 1 \ \
°O- F /y� °�/ ZZ� ' LOT 146
1.16 ACRES 01
50,566 SO. FT. \ \\ —I W I
D
�40 LOT i 4 5
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