HomeMy WebLinkAbout020-1302-80-000 ST. CROIX COUNTY ZONING DEPARTMENT ;-
AS BUILT SANITARY REPORT
Owner 710e k PREME
Property Address 4)j Or ny �� 1 �-,
N � 1 9«9
City /State N "So= r s Sy��h -,... f -
t ST GRW �
Legal Description: �,?., .z COUNTRU" f
Lot Block — Subdivision/CSM #
t/� t /4, Sec. --�, T N -RAW, Town of u,//.s,l PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
`Tank manufacturer a �f Size(OPC /0c1 Setback from: House Well P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: h- Width 3 Length ? 5 Number of Trenches Z
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark rill dl L 2 Elevation /
Description of alternate benC�7nark Elevation
Building Sewer �� ST/HT Inlet 1 00, ST Outlet f- ? PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover »D ,
Distribution Lines l D , 9,(0 (Z)
Bottom of System
Final Grade O O ( )
Date of installation 111 41�f Permit number '>`��// 1 7 State plan number
Plumber's si nature cl License number a2615�2`- Date W//
Inspector
Complete plot plan Q
1
NOTICE Please provide the following:
• 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.
PLAN VIEW
W� i�41
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INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Saf2ty and Buildings Division Count
INSPECTION REPORT St. Croix
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)]. 344617
Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.:
Town of Hudson
"CT Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.:
eC 49 �' Z It r r 020- 1302 -80 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic lio6d Benchmark
Alt. BM Q 9
ZV
Aeration Bldg. Sewer q, loop � s"
ing St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet S l ode. Z'
TANK TO P / L WELL BLDG. Air I to ntake ROAD
Air
Septic ± U 0 / b l t 16 1 NA
D A Header /Man. 7.
Aeratio NA Dist. Pipe / " BOG'
olding Bot. System /,0 tv y 6
PUMP/ SIPHON INFORMATION Final Grade
' l)
St �r
Manufacturer Demand cover
Model Num
TDH I Friction stem TDH Ft
L oss
Forcemain I Length Dia. Dist. well
SOIL A RPTION SYSTEM 7- P✓
BED //fREN04 Width r Lent F No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMemstems �J Z' DIMENSION
Manufacture :
SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM
INFORMATION Type O CHAMBE Moe u be :
SS' 1� r
System: J �
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length —10 Dia e ms Length —3r/ Dia. Spacing _:� I tI A 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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: /I /1 d /fI Inspection #2:
Location: 751 Oriole Lane, Hudson, WI (SE1 /4, NE1 /4, Section 7 T29N -R19W) - 27.29.19.1496
sewer lam,,.
o f YAW--:5 & 1 1r 4a C4
Plan ~i ❑ Yes ❑ No
Use other side for additional information. p G
SBD -6710 (8.3/97) Da4 Inspector's S ature Cert. No
ADDITIONAL COMMENTS AND SKETCH
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SANITARY PERMIT NUMBER:
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• Safety and Buildings Division
SANITARY PERMIT APPLIC 2 01 W Washington Avenue
Visconsin In accord with ILHR 83.05, Wis. Ad �� P O Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, o spa er not I,l,, unt
than 8 1/2 x 11 inches in size: ` 7
• See reverse side for instructions for completing this application � A s e San ary ermit Number
Personal information you provide may be used for secondary purposes j�CD eck i ievi on to previous application
[Privacy Law, s. 15.04 (1) (m)]. ��V� NTy� State Pin l . Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFO
Prope Own er Gl.il St 8 �? Z`r "�
1 aj T , N, R (or)
Property Owner's MaillWg Address Lot Number Block Numbeer
O A
Cit State tip Code Phone Num Subdivision Name or CSM Number
/ ( > �v r�I ' T—
II. TYPE OF (check one) ❑ State Owned 11 C Nearest Road
3 ❑ village L / Q j Ck.`tN
Public 1 or 2 Family Dwellin No. of be drooms Town OF
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
- a - i _Z`i. l 1 9 10
1 ❑ Apartment/ Condo a�� f3 L' Z '
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 line A. Check box on line B, if applicable)
A) 1. �S New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------ System _______ System_____________ Tank Only______________ Existinl,- System _________E ---- 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
110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 N Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit ✓ — 3? 74 �iea c/� ❑ ault Privy
14 E] System-In-Fill ' y 01 h /• e g 74 �
VI. ABSORPTION SYSTEM INFO MA ION:
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) Tr t cy4 i 50- Elevation
'V 4;2 !03 , S Feet /07, Su Feet
VII. TANK Capacit gallons g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tank
Septic Tank or Holding Tank i6ty — i LJaz k i, L f' ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb "s Name: (Print Plumber's Signature: (No tamps) MP /MPRSW .: Business Phone Number:
✓ i w► �. / i� !) kt °�i 772 3 L /
Plumber's 4ddress (Street, City, State, Zip Code):
al vfk ►1 59h L�-J z, a
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved #nitary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps)
Approved E] Owner Given Initial d'D Q
Adverse Determination �� I Surcharge Fee)
�[
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 IRA 1 /97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be 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:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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. N
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.
VIII. 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 81/2 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.
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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.
JOB ea4
TIMM EXCAVATING SHEET NO. I OF
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY l DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1®lrrc, Groton, Mass. 01471. To Order PHONE TOLL FREE 1-BW225-M
Wisconsin Department of Industry, SOIL AND SITE E V'A LU AT I ON RE PORT � Page � of 3
Labor and Human Relations 1
Division of Safety d, Buildings in accord with 11-1-11`143.05, Ws. Adm. Code
UNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in siia Plan must include, - but . PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and i� pf slope, "0 or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
REVI EW
PROPERTY OWNER: i/ A'�vl� PROPERTY LO
4
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A
PR �U,y� / �f S /
f o - G4 4IAy y GOVT. LOT � 1/4 1/4,S 2 T Z9 ,N,R /f E (or) W
PROPERTY OWNERS MAILING ADDRESS �2i8 �ipv��Q ��` LOT # BLOCK # SUBD. NAME OR CSM #
33� ,�oB TS ST y� 33 }{ t)M Ri f'� H I'lIS �Pti/1Sr: 2-
CITY, STATE ZIP CODE PHONE NUMBER []CITY �111LLAGE N NEAREST ROAD
T,uG �!N 55/0/ lG�) z2 -5SS5 t fUpso,.�
Vf" New Construction Use ( piesidential I Number of bedrooms Additxxt to existing building
( J Replacement ( ] Public or commercial desaibe
Code derived daily Now boa gpd Recommended design loading rate / bed, gpolft trttcit, gpd/ft
Absorption area required � bed, 111: / 6719 trench, ft Maximum design loading rate � bed, gpd/tt we
Recommended infiltration surface elevation(s) S� P 9 3 It (as referred to site plan benchmark)
Additional design / site considerations
Parent material S' 5 GG !� v�(°Kti D T Flood plain elevation, if appliFable It
S -Suitable for Syst cmv of MOUND IN-GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U - Unsuitable for stem CC'S 0 U ❑ S L�Sl1 C�3� 0 U Mix - � U ❑ S Ci? ❑ $ L
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bour�ry Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ttlydt
[3 2— t1" e 3 LF AJ N
Ground 3 y'3U /D S" Si� �•� 4 S 5
/a 3 e1 5L f t /p ,C' 14 — f S
Depth to
limiting W S teSt sit APPR VI DD
fac
Remarks:
Boring # 5 1 If 56,E � S z of - S i .6
13 L - Z/ �D J�iP 3 /3 --- 5 / Z 41e �,f S v� S ( .
3 / -5z io ,e
y s/ ��► ivy 'M A'e 7,6 �s . .
Ground J c
05. 7 z ft.
Depth to
limiting
factor
Remarks: /
CST Name : — Please Print 'P O Q E R T '4 L((? I' Ck 7— Phone: 71J _ . 3 P6
F �J S C�' Ne i L P D • R UP S O.J W �S S� /�O gnature:
Date: CST Number:
ORIGINAL
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z 3
PARCELIA.# Ga 7 33 0 f131;
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou ckvy Roots GPD /ft
In. Munsell Qu. Sz. Conl Color Gr. Sz. Sh. Bed Trench
e- 12- /6 � ,312_ �— S✓� S' e M�'�/ S /U� S
y 11 - 26 /o 3/3 �Si /, Z�+ 1�,� •,nf /` es Zf • 5 �
Ground - Id y S� Z �ilr� ij ` �C S — • S
elev. . y,PArr -/y
ye S 1� nor s o , s �., � • s i - G
Depth to
_
limiting r
factor
I
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Remarks:
Boring # / 10;1A i�Z CD, Afrr& —p S / // � e fit( � �2 S �-� N
Ground
elev. 17 Z - 7S S. 0,
,
i
Depth to i
limitig 0
fac
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Remarks:
Boring #
/S -21 /o c s 2-f
Ground - 7, S YR y 9 y ��► 9� �rivfc' cs 5
y'.
elev. Y y/ 6 . s -
/d 7 SL ft.
r
Depth to A ;
limiting `o s y `{�' 46A, 2
factor
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Remarks:
Boring # _
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Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
cen eoon�o nc �nm
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ,
Mailing Address
Property Address �-
(Verification required from Planning Department for new construction)
City /State Y✓ }�^ a�_ �C ✓ Parcel Identification Number.
LEGAL DESCRIPTION //
Property Location S �F 1 /4, /Ur ' /a, Sec. , T ZF N -R LI W, Town of 17 i
Subdivision AZip Yi S E Lot # 33
Certified Survey Map # 52- ° rte , Volume , Page # �2
Warranty Deed # _ J��)���o , Volume /3 , Page # ���
Spec house ❑ yes 'ono Lot lines identifiable ZF 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.
I/we, 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
I septic ystem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
three y expiration date.
- 7 /a y
SI ATURE OF PLICANT DATE
OWNER CERTIFICATION
I (we) certify all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pro described ve, by virtue of a warranty deed recorded in Register of Deeds Office.
z ,
SIGIATURE OF APPL ANT DATE
* * * * ** Any information that is mis- represented may 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
DOCUMENT NO. WARRANTY DEED
! STATE BAR OF WISCONSIN FORM 2 -1882
' -P
Humbird Land ®
Corporation, a Minnesota Corporation � ��
_..... ._.._ ............ . ............ - ....... I RKd�suxMe r�
_.._......... _ ......... .... ...........__._............ _. _....._..........
_ 1 JUN 0 3 1998
........
!.. convl•yx auul warr :ulta to .. Joseph..T_, .tind.Joseptilne.,A., Ryan, Husband - __ - _- 8:30 A M
and wife,..
_ .
_ . ............. *645W of heeds
....... ......... .......... I ......
......._....... ........ _ - .__.._... -_
.. .. .... L
ctun.t ro —� '!
_....
YM i, ,� „
j ............... -- ...................... ..........
the following described real estate in ...... St. Croix -- County, —' - --
State of Wiscunsin:
Lot 33, Humbird Hills Second Addition, Tax Paretl No:
Town of Hudsdn, St. Croix County, Wisconsin
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I� � ANSFER
FEE
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f This J s. not_._..... - , _ homestead property.
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61Ak (is not)
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1' Vxceptioo to warranties: Casements, restrictions and rights -of - way of record, if any
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Dated this .. ... 28 th ........................... day of - - -- May ......., 19.98..... !I
i HLMBIRD LAND CORPORATION `
s (SEAL) f .(SEAL)
...... - ........ BXr.. ............
Austin J. Baillon, Its President
..... ... ............• ................. ....( -EAL) ...... ..... ........... _..(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
._._._. - STATE OF VVAM1t?(gIN MINNESOT
................ •--. ...... ........ .-. ......... ........ ---- _.......... I.....— Ramsey ........ ............. .......County.
at_lillarAicated th day o. .. ...... - ...... Personally came aeforo me this _• 28th day of
May-- . ............................... 19.99.... the abo -c named
Atlst_i n- J,__Ba i l l on Presi dent of ....... .......••_,_ .......
r= • Numbird Land Cor oration
TITLE: MEMBER STATE BAR OF WISCONSIN
- --
(If not, - -.-•.................... ............. -•- - - ----
-- - --.._....-- .......... • . ......................... _ ...............
authorized b y § 706.06
, Wis. Sta *.s.) .
to me known to be the pe rson ..........., who .xeclt± ed t,. `Z.
foregoing instrument nd acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ..... l/VL/1�.�.�.1A4 1 1 �1�MV,r. ^J.1�N•A^hrl ^.°
1 �i( i 1 3 t.1 : fJN
?. ✓ .... :f �TiTA
Hyrq¢i.rd- Land. Corporation ........ .Paul A. Bai i l on <' Y:. a7Jt, GC)IINTY
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................ ........................ Notary Puhlic
(Signatures may be authenticated or acknowledged Both 13� Commission is pernlanent.(If not, state expiration
are nat necessary.) .late- .._..January 31 .. .................... .....
O .. { •Nu.nes ... nct.ann.+ nicnins it; any capacity ehwild be lyvetl ;r, ih,res.
OL
LOT 34 g 0
2.02 ACRES - 00 1 u
\ 87,932 SO. FT. _ j
LOT 27 \ ': \` ••' N ' —'
2.14 ACRES PONbING
93,106 SQ. FT , EASEMIENT •. \\
EL.= 972
S89 299.46' \ 1\ ; H84 "E
198.7 W
A `\
LOT 28 \\ \� Nf
2.23 ACRES
97!078 SO. FT. I
I 33' 1 33'` 1
I
EASE .. O LOT 3
w {p O 2.01 ACRES
No 87, 369 SO. FT.
N87 °52'18 "E / 330.79' w
EL. = 969
)NDING
I 1 1) to o6 P��
3EMENT V Pl ay
LOT 29 N w
2.00 ACRES m w I — O
87,164 SO. FT. p N89 "E 223.78' i I
I /
' CHICKADEE — LANE SECTION CO
{' 1 "E 230.51' w
N89 ° 39'42
• V
o
S84 °30'57 "E 317.62' I o O
0
t _
I 6 6' w 1f
1 m I '
CA
c, I I
LOT 30 LOT 32
OD 2.01 ACRES
2.00 ACRES D N 87,649 SO. FT. w
m �
87,162 SQ. FT. z OD 0 z n
0 O
! ®�• 1 2 CJ1 Z
LO m
o
W m
PONDING
EASEMENT m /
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