HomeMy WebLinkAbout040-1077-95-000 (2)8.,19, 2 99FPRIVATE SEWAGE SYSTEM
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
.GENE § RAL INFORMATION �ATTACH TO PERMIT)
I
Permit Holder's Name: City D Village � Town of:
BM Elev.: BM Description-.
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosi ng
Aeration
Holding——
TANK SETBACK INFORMATION
TANK TO
PI L
WELL
BLDG.
Ventto
Air intake
ROAD
Septic
j7)
NA
Dosi ng
Aeration
NA
Holding
tl
PUMP FORMATION
Manufacturer Demand
Model Number GPM
TDH Lift
Friction S stem �A TDH Ft
11, 2
Lgss ��6a d
Forcemain Length d- IS5 Dia- " ,+* I Dist, To Well
ELEVATION DATA
STATION
BS
Benchmark
_t, t
X.
Bldg. Sewer
St / 4f inlet
6,-7
St/#f Outlet
Dt Inlet
Dt Bottom
�
Header4;htiw.__
Dist. Pipe
Bot. System
Final Grade
I
r4o
A9300295
HI F S ELEV.
('6
A 6j ,
SOIL ABSORPTION SYSTEM
BEDWidth Length No- Of Trench;! PIT No -Of Pits inside Dia. Liquid Depth
/TRENCH DIMENSIONS
SYSTEM TO
DIMENSIONS P f L BLDG WELL LAKE/STREAM LEACAMG-1-
Manuf
SETBACK del Nuiii er.
0
INFORMATION Type 0 f r j- A..; L(
System: OR UNIT
DISTRIBUTION SYSTEM x Hole Vent To Air Intake
Header HV��� Distribution Pipe(s) x Hole Size Spacing
Length Z Length Dia- Spacing
Dia.
Mod
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
x 2 e
xx Seeded /Sodded x M I Zt1e4--
Depth Over Depth Over xx Depth Of
0 Yes ❑ No
Bed /Trench Center 0
Bed/ Trench Edges Topsoil
COMMENTS: (include code discrepancies, persons present, etc-0- a -e-
17
LOCATION: TROY 19o28,19,299F
Flz(
Z Q�
A, IJ2-
?
--Z 7
Plan revision required? E] Yes
Use other side for additional is ofor on.
---
"-Ae inspector's Signaturel Cert No
SBD-6710(R 05/91) . . / Date
E967
STC - 104
AS BUILT SANITARY SYSTEM REPORT
0 W N E R
C4
ADDRESS ��,C /-/0 eVI t4l lfp
RU-4 gi5g)n
�g
SUBDIVISION CSMV -4� (0 LOT
SECTION- T N-R Z2 W Town of
ST. CROIX COUNTY, WISCONSIN
r
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Aif AT 7- C/'o*
)&d�vc 14,1141ei(
'67� L L) /0 0. 00
Pe irrcr 4
ell
12
far
w,4 /AJ T )L/L
AA ry o AJ 41-r
-<-1-1 q0 pve —
r, 4 YAj t-
or- 4e?74)
r
AID 'el-Ir
p ja;
6A 4. 5�z e 1-4.Aj K 4%) / 7
Aj I
41 57c,�-/ 4/u '/Wo
z Zj'5'0,k,,e-rlcwAJ / #411,eOLAc-o 4)e i-/�, d7 Aid 0,
CA,(. ),ir7 r11An1d,&e TNDICATE NORT11 ARROW
r-se 0 f th I s -f 0
Provide setback �ind e-le-vati-on information oil reve
c
Provi.de 2 dimensi.ons to center of- -'Over
BENCHMARK:
v &J.
ALTERNATE BM: ru4t�Aj 40 4 7-1V Aj
r
SEPTIC TA_NK(� PUMP CH.A.MBER /'-HOLDING .-TANK INFORMATION
Manufacturer:— 5 E Liquid Capacity,, -
0 641-
Setback f rom: Well House
Other
Pump: Manufacturer- Modelt_,_�(, Size
'141
Float seperation
,/S Gallons/cycle: - z� 0� (!�S,�
Alarm Location -
SOIL ABSORPTION SYSTEM
Width Length— Number of trenches /- &�o
Distance & Direction to nearest prop. 1-
ine:
t4 lap
0/
Setback from: well: House E01' Other &Je5-i _ �<F #1
ELEVATIONS
Buildinq Sewer fO. ST Inlet.- <eO,. S-1 ST outlet
PC inl,et PC bottom /7
6/ 6
, e7?
2Z Pump Off
Header/Manifold Bottom of system
Existing Grade /1-919 7::�" Final grade L.)O. �?o
DATE OF INSTALLATION: q
PLUMBER ON JOB:
LICENSE NUMBER:
TNSPF-,CTOP-
3/9 3: j t
UMERMOrmon SANITARY PERMIT APPLICATION COUNTY
(�431LHR In accord with ILHR 83.05, Wis. Adm. Code S7__ C i
Ln
#
STATE %QaZ,&PdIT
ot less than
—Attach complete, plans (to the county copy only) for the system,, on paper n L'
[:] Clec' application
81/2 x inches in size. kifr visionto revious
—See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
1/4 1/4 S 11,P T N R 119
,71VO d22a. C BLOCK#
PROPERTY OWNER'S MAILING ADDRESS LOT #
Z.Z -00�
'ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
CITY, STATE
X- Al
//Z., e, i 1, REST ROAD
Li CITY NEA
11. TYPE OF BUILDING: (Check one) El State Owned 0 VILLAGE: 7A- /I
0 TOWN QF:
FPublic 1 or 2 Fam. Dwelling—# of bedrooms PARCEL TAX NUM BER(S)
111111. BUILDING USE: (if building type is public, check all that apply)
10 Apt/Condo tional Facility
2 Ej Assembly Hall 6 Medical Facility/Nursing Home lo F-1 outdoorRecrea
3 El Campground 7 Merchandise: Sales/Repairs 11 1:1 Restaurant/Bar/Dining
4 0 Church/School 8 El Mobile Home Park 12 F-1 Service Station/Car Wash
9 0 Off ice/Factory 13 El Other: Specify
5 F] Hotel/Motel
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. 0 New 2. F� Replacement 3.0 Replacement of 4. El Reconnection of 5. [:1 Repair of an
System System Tank Only Existing System Existing System
B) El A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 N Seepage Bed 21 E]Mound 3o F� Specify Type 41 0 Holding Tank
12 Seepage Trench 22 F] In -Ground 42 11 Pit Privy
13 0 Seepage Pit Pressure 43 El Vault Privy
140 System -In -Fill
V1. ABSORPTION SYSTEM INFORMATION:
5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE (Min./inch) ELEVATION
'0' REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) C) t�
.G1 Feet /0/,/0 Feet
a --- WNEEEE�
CAPACITY Prefab. Site Fiber- Plastic Exper.
V11. TANK in gallons Total # of Manufacturer's Name Concrete Con- Steel glass App.
INFORMATION New xisting Gallons Tanks structed
Tanks Tanks F�
Septic Tank or Holding Tank Z2 �L_o Ll 1
Lift Pump Taniusiphon Chambeu.ZE—b
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's signature: (No Stamps) W/MPRSW No.: Business Phone Number:
1000
Plumberps Address (Street, City, State, Zip Code!):
JX. COUNTY/DEPARTMENT USE ONLY issuing Agent Signaure"'o mps)
Sanitary Permit Fee (includes Groundwater Date issued
2
Disapproved Surcharge Fee)
Ej Approved I F-1 owner Given initial I I /a
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
I SBD-6398 (formerly Plb-67) (R. 11/88) 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 sapnitary. permit may be renewed before the expivation date, and at the 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 Per-Mit issuing authority.
4.. Changes in ownership or plumber reqwres a Sanitary Permit" Transfer/Renewal Form, ISBD 6399) to be
submitted to the county prior to installa;ion.
5. Onsite sewage systems must be properly
I maintained. The septipc tzank(s) m ust, 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 & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
L 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,
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV Type of permit. Check only one in 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 in #1-7.
V11. Tank information. Fill in the capacity of every new and/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.
VIIL Responsibility statement. Installing plumber is to fill in name, lk-ense num ber with appropriate prefix (e.g..
MP, etc.), address and phone number. Plumber must sign appli'cation form -
IX County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8Y2 x 11 inches must be submitted to the county. The
plans must inchUde the following., A) plot plan, drawn to scale, or with Complete dimensions, location of
�c
holding tank(s), seplic tank(s) or other treatryient tanks; biuil�ding sewers, v�.,oe,
streams and lakes; PLIMP or siphan tanks; distribution boxes- Q.o-! absor
pton �-,ysterv--; rsep lace mcmt system
areas, and the. iocation of the building served' 8) horizo0tal ai
.1d Ve. clkio,-s refe-re
,;nc,e points,
C) complete Spec', fications for purreps and confrols; dose voiurne: elevatii-,,"! differences; friction pump
4
performance curve- Purnp model and pump manuMacturer- D) crosR ser,,
J
-f thE,1 soil absorpfllorl systern f
required by the county; E) soil test data on a 115 form; and F) all siz
F ing ir-formatiorl-
GROUNDWATER SURCHARGE
XN-sconsin Act 410 included thtil creation of surcharges (fees) for a numt--.C,
regulated practices which can effect groundwater.
4
The ryioniu�,s ihose Surcharges are used for -o u #A
i n,,
g q t t1wki. jr,
water contlaty0nation irivestigations and establishment ot stalhAaro,
S8 D-6398 (R - 11 /88)
47- A/- L-J. e"'uP"ire
00- cu "
/ L /?7- Jq
4W� 5 OR 3 6
�AIAJ. <42
4 b-r %� 3
u-i
1�f,AK PO)AJT-, 6'fA V'T
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ll�vlo,w N C
A
6 �
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F PLB 67 1
PLOT & CROSS SECTION PLANS
LAPPA 13HO5. F:XCAVAf ING INC
L- PLUMBING UNIT
PROJECT
60
IX
494Z <�P71e -774 Aj K /7-// 'y 15'e,4 Vo
IAJ
Z ,,Aj XAJ'O 1
005 ) A) C.. 0 C,,(T
Alq *Olfc,
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lilf o
- ), I Aj,!�'
vc"")
"Q,Q 46
cKvi
IAj 14 /6 NO
0 L4 ',J T-,e---
SCALE
FRESH AIR INLET AND OBSERVATION PIPE
MAXIMUM 120
ABOVE F1 -HAL RADE
(7.7 711 Ir 4r
-L-V 7
MAXIMUM OF 42* ABOVE.
PIPE TO FINAL GRADE
IVIAHZ�H HAY 08 SYN-THETIC COVERING I I
MINIMUM 2" AGGREGATE
OVER PIPE
OISTRIBUTION PIPE
ELEVATiON BED 6" AGGREGATE
BOTTOM PER SOIL,�.,%. BENFATH PIPE
TEST 1 5
c FT.
APPROVED VENT CAP
4* CAST IRON VE14T PIPE
SIGNED:
I -,Z-
A,w
LiCENSE.
DATE: .3
TEE SOIL TESTING BY:
IL ::1
Fj/-a)fwlo � �c a r3r�-- �*4 T1.2,39
PERFORATED PIPE BELOW
COUPLING TERMINATING
AT BOTTOM OFSYSTEM
oe
e-
4e r5 o
3v 0//
La
&tA
7 Y?
A(-j
e
eveK7 're Poo
2
qq
qp 60 5
fi okc
21 r e Ae-
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le
Dr
I,[
V-0—M-16
DEPARTMENT OF
INDUSTRY,
LABOR
REPORT ON SOIL BORINGS Al
AND
HUMi-%N RELATIONS
PERCOLATION TESTS (115)
(H63.09(i) & Chapter 145.045)
A; IYO
LOCA ION., SE TION:
OT NOJd
V4 TOWNSHlP/NftJNtCtPA-L-iTY: =NO.,
4 4
:4d t /T?s N/R E (o
j T
COUNTYP
07.
MAILi DD E
fro C
USE
.... .......
KI IN 0 - B E D 19 M�S � :
2R- e s :ii d:e- n c e _E_0MMr-r1k,1AL UtSCRIPTION: DATES C
------------- ffN�ew DReplace PR(5FM
RATING: S— Site suitabla for system U= S,
Z-0 �NV E N T 10 - AL: ,I'll,, 1� ___ its unsuitable for system
lioll iZI LI 1 11, D: l, �i: ;::i:;::
IN-GROUN5:PRE§S_AURE: ��OLDING TAN N C
IDS EU KI EM-IN-FILL :RECOMME
� =E1 U RS
[JU
=� MR FA
e I a 'io
It Percolation Tests are NOT required
�e'ts are N OT reqt
If P F"0=
Eunder
IGN RATE:
_n
0
s.H63.09(5)(b), indicate:
If any Portion of the tested arei
Floodplain, indicate Floodplain
PROFILE DESCRIPTIOM-4Z -,/ . Zo
DEPTH WATER IN HOLE L:,i I FIME
�NU'MBER' INCHES AFTERSWELLING INTERVAL -MIN.
P_
..........
P:: .............
K IF 0Rc;r-RVr-n iccc A
9l,FLA I IUN I ESTS
DR5 ATER LEVEL-04-C—HEs
P:;RIOD 1
P
J =2f,
/ - X
.............. ..................................
PLOT PLAN: Show locations of percolat' ings and the dimensions of suitable $oil areas. Indi Late sca
J vertical elevation reference Points and show their locatiun on the P'lot Plan. Show the surface elevation a
zontal an( 'On tests, $oil bori
of land slope.
SYSTEM ELEVATION
TT
77 91
A /S x _;7
x I-
=1,31k
1, the undersigned, hereby certify that the soil tests reported on this fur in were made by me in accord with the procedures
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and bel
N r I
TESTS WERE COMPL
Xc.
A A
�DD: IR 7ES S
CERTIFICATION NUN
4.
_1S I CiN A T U R E:
DISTRIBUTION: Original and one copy to Local Authority, pf()pLrty Owner and Soil Tester.
DILHR-SBD-6395 (R. 02182) — OVER —
f ORM NO. 985-A
k C Woof comp"
t3j
fs N? F I L E D
Lj
F I L E D
SEP261980
JAMES 0' CONNELL
it
too 11tj
6-3A! of a
Realiter of Dimah
x
-Ir 64 Croix Cownly,
A'
u-n a t t e d CERTIFIED SURVEY MAP
a d
vyllconi
n s
�PC4
356,171
'171
NO 1 3 1
298.001
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COMNEHPNSIV� P,.,.i._
R=80'
ANDIONING r
-.0
N,4 a,0 4 2' 3 8 W
OF V)
W
,,�:`96. 96k
57 Y
19�.
cn
r-2 POINT OF
wl
7�4
BEGINNING
0 06 900
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0
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330. 00'
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SOO 1 3'50"W
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2
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RIGHT-OF-WAY
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ROADWAY EASEMENT
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79'
6 G. 0 2
322. 81' tD
S0055'52"E
COUNTY TRUNK HIGHWAY "Fll
N 00 1 3'50"E
3965. 42'
1305. 30' N 001 315011E EAST LINE OF SW 1/4 0
DESCRIPTION
A parcel of land located in the SE1/4 of the SWI/4 of Section 19 T28N R1911
'rown of Troy described as follows Commencing Lit the S1/4 corner of said
4
Section 19; therice N0013'SO"Ii (true bearing) 130S.301 along the East line
of said SWI/4; thence N89'3811V 660.001 alonly the North line oC said SEI/4
of the SIV114 to the point of beginning; thence S0'l3'S0"W 330.00'; thence
S890381E 581.931; thence SO'SS'52"E 322.81' along the Westerly right-of-way
line of present County Trunk Highway "F11; thence N89'4211q 1221.10' along
the South lineof the NI/2 of said SE1/4 of the SWI/4; thence NO'10'30"W
6S4.17';'thence S890381E 637.261 along said North line of the SEI/4 of the
SIVI/4 to the point of beginning.
Contains 13.87 acres. more or less.
I certify that the above description and map are correct and that 1 have
fully complied with the provisions of Sec. 236.34 of the Wisconsin Statutes
and Section 5.4.2 of the St. Croix Coun Zoning Ordinance.
Date: October 19, 1979.
Revised Date: 1,ebruary 27 1980.
Francis '11. Ogden--18-8824:�x Job No. 1196
Ogden Engineering Co.
123 E. Elm Street
Rive i Falls, Wisconsin 54022
FRANCIS H. 1.
)L
OGDEN
I hereby certify that this map has been approved
S-882
by the Town Board.
LLS)
jr RIVER FALLS,
-7 % Wis.
Date
10
U R%A
LEGEND let SIASO
SECTION C0RNI7-.R NIONUMEWl" FOUND,. BERNTSEN CAI
I" IRON PIPE WEIGHING
1.68fi/LINEAL FOOT, FOUND
0 111 x 24" IRON PIPE WEIGHING
1.68#/LINEAL FOOT, SE-T
EXISTTNG FENCE LlNE
CURVE NO. LOT NO. RADIUS
1-2 80.00,
3 80.001
4 80.00'
CURVE DAqA TABLE
/-% F-% T N It N I- It T N 'r V T f-%
Nz.V 1�) , el I'T 14 / . .5 41 1 ZZY"55 1 221,
N38007'39"W 12S.23' 103000'42"
NWS0102"E 140.SS' 122'DS4'4 ''
SURVEYED FOR OWNERS
RICK CHERRY AND STEVE PETERSON Steven L. Peterson
2727 WKNIGHT ROAD Richard A. Cherry
'�ORTH ST.' PAUL, MINNESOTA 'S5109 Gregor), K. 11CCI
2727-McKnight Road
NOTE: THIS CERTIFIFI) SURVEY MAP 11 E P 1, A C. E S N. St. PaUl. N111111. SS109
'rilE CERTIFIED SURVEY NIAP- -RECORDI'l)"
Mr. Mr Richard Jackson
TN V 0-LD -lE7-2 P A C-E S S 6 P. D () C EN 1424 Hallam
U346822. I Malitomedi, Minnesota SS11S
POLICY OF 11-1E ST. CROIX COUNIN CCktpRy:,nsjVE- pARKS PLANNING AND ZONING CaMIT-ITE
7 -ivate road-
'111C roadway shown on -Hiis maj) is- a 1,0. vate roidVa Ally )wiinLeriance costs of the pi
%vay, after its approval by the Zonitw AcIlidnistrator as a staiWard road, -o - ra t
shall be- shared pi
by the a(Ijoining property owners. SI)OLIId L110
`17iis instnzient drafted by Robert K. Krisak.
i adtvay be takeii over by a municip:tljAy as!
'o.
a public road, ilia ill tellance costs tliereafter
would be a piiblic expense.
lift
Vol Wne It Paire 993
0
U
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS FIRE NUMBER
Z-,
CITY/STATE --Zip
PROPERTY LOCATION:-50.6 1/4,
1/4, SECTION- T Z N-R -W
TOWN OF St* Croix,county,
Suffaiv Fr1eilIL— cq LOT NUMBER 3
Improper use and maintenance of your septIc system could
result in its 0 premature failure to handle wastes. Proper
maintenance consiStS of pumping out the septic tank every three
yea-rs or sooner, if needed by a licensed septic tank pumper. What
you put into t�e system can af f ect the f unct ion of the septic tank
4
as a treatment stage in the waste disposal system,
St. Croix County residents may be eligible to receive a grant
f or a maximum of 9 60% of the dost of replacement of a f ail ing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, w ith the
requirement that owners of all new systems agree to keep their
system properly maintained.
T.he property owner agrees to submit to St. Croix Zoning a
certification 'form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1)� the on -site wastewater disposal system is 'in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
SCUM.
I/Iqe, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix co. zoning Officer within
30 days of the three year expiration daLel,
SIGNED:
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
S T C - loo
Th's application form
is to be completed 1
�he owner(s) 'n full and signed by
Of the property being developed . Any inadequacies
will only result in delays of the POrmlt i9suance, , Should this
development be i�tended for resale by owner/cohtractort(spec
the h
house), thenta second form should'be retained and completed w en
property' is sold and submitted to this office with the
appropriate deed recording.
----------------------
Owner of property���
Location of-propertySS 1/4 1/4, Section
_N-R W
Township
T
Mailing address
Address of site
Sut�dj*:vis1o-n rraim �s W1. V0 Lot no,
Other homes on property? yes_ No
Previous owner of property
Total.size of parcel e-da��
Date parcel -was created
.01
Are all corn ers and lot lines identifiable? L-�-—Yes No
Is this property �)eing developed for (spec house)?.Yes No
Volume and. Page Number as recorded with the Register
of Deeds.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - -- - - - - - - - --- - - - - - - - - - - - - - - - -
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
I
A WARRANTY DEED which includes a DOCUM
ENT NU`MBERf VOLUME AND PAGE
NUMBER & THE SEAL OF THE, REGISTER OF DEEDS.
certified In addition, a
survey, if available, would be helpful' so as to avoid
delays of the reviewing process. if the deed description
.references to a Certified Survey Map, the Certified Survey Map
shall also be required,
PROPERTY OWNER CERTIFICATION
I
I(we) certify that 'all statements on this form are true to the
best of my (our) knowledge that I (we)
am (are) the owner(s) of
the Property d;nscribed in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. and that I (we) presently
own the Proposed site for the sew—'
age disposal System or I (we)
obtdined an easement, to run the above described property, for
the construction of said systeme and. the same haG been duly
recorded in the office of County Register of deeds
No. as Document
Signature of apt�licant
Date of Signature
C o a pp 1 j'6a n�'t
Date of Signature