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HomeMy WebLinkAbout030-2090-40-000 Q O O O M ^ 0 o Oq O 0. O ti 'I O O Gt' I O Z N N O 6 Z C 3 (0 lL c O 3 a 3 Cl) Z y E N Cn j', O P Z d y N H ce) Z d m O c C C9 I'',. co O Z d c m 2 d ° fA I- r O N Z c '2 ° co jq~ N O 3 co O N N • U) N ) C O O U 1 O O N a O Z m z o N Z d N 'p E E I ~ A Y N C - - a Z L c C) Lo = N Gl N C 0 00 00 p O D d c0 '~6 N N f'1 00 N U) U) rW~`J a LO H F- H E L) O _ O O O O O Z O O •N a a a E ° o u) r W N ° 0) 0) J = y to U! rn rn N LO > co { .W N O O C) o N O '?3 j 00 ao D N N z N 8 -6 .2 ►i ° Ili a ° N C °0 3 (co 0 U) c O O O N N o ra c) + O LO ~ c O C N 0 0 0 ~i n L Of c 'O N N N O c cs N ~ w O N N D co W N Gc.S O N r~ N M E M N 'O W c N O f~ U) O O U • O 'tea O N CO W N O Z Z 0 Cn i.r CC r v ~ L it C N 7 L: CL 0 CL 4) a E c c S rr~~ L 7 `~.1 A 0 CL O V) V f • y . STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER LsADDRESS "A zo~INGop SUBDIVISION / CSM#,~„~~ LOT SECTION ,.2v /_T _Z,1, N-R-_W , Town of _ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Z /u I A3„ A A A Cf 7s ` _ b ~ =~i'o fcJ- iZ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ;,r ALTERNATE BM:„~ 95~ 7f/ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: b3v~ Liquid Capacity: Setback from: Well_ House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM IAJ4/,41 Width: Length_ 7,5-- Number of trenches Distance & Direction to nearest prop, line:_ Setback from: well:_ House Other ELEVATIONS Building Sewer--~ ST Inlet: -2:L - ST outlet: PC inlet PC bottom Pump Off Header/Manifold ??.7;?- 9.~ Bottom of system 9' Existing Grade Final grade DATE OF INSTALLATION: ~11~;/_ G PLUMBER ON JOB: LICENSE NUMBER: 2 INSPECTOR: 3/93:jt ~ poo,/ f " 561233 STATE BAR OF WISCONSIN FORM 2 - 1982 WA RANTY DEED , DOCUMENT NO. VOL T?46 PACE 5 35 _ - _ _ REG,STF R'S OfFI SE t Thomas K. Okers: rom and Nona Lee Okerstroms- ST. CROIXCTYNINI husband and wife, ""%drw• JUN 1 9 1991, conveys and warrants to 11 :30 AM ifey with .~~.1... s1J.. survivorship marital property ttvylsta,vtDeu" a -«15 SPACE RESEF.EO FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate :n S t . Cro?_ x _ County,;22 .f State of Wisconsin: MIOAMERICA 13ANK HUDSON , " 600 2nd s~ Hudson W 1 SW6 PARCH 4"TIFICAT~JN NUMBER t r ' ~T Lot 8, Arbor Hills in the Town of St. Jose;~h, St. Croix County, Wisconsin. TOGETHER WITH an easement for ingress and ~.gress over that part of the 'y SW1/4 of SW1/4 of Section 19-30-19 lying Nly and Wly of County Trunk Highway "V". { This i s not homestead property. XNX (is rot) ' Exception to warranties: Easements, restrictions= and rights-of-way of record, if any. Dated this day of j un a A-D., 19 9 7 st (SEAL) (SEAL) • T I Nona i-ee OkP (SEAL) ` 3V_&'rcG4,~ J ~ _ (SEAL) l AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Vl~isconsin• uMq-- EK St. Croix a. • County/. authenticated this day of • personally c~R befixe nic this C r7 day of • June , 19 97 , the above nawed * Thomas K. Okerstrom and Nona Lee • • Okerstrota, husband and wife, y TITLE: MEMBER STATE BAR OF WISCOi t ' (1[ not, ~~i C~ • • . authorized by §706.06, Wis. Stats.) 1~Vtjri~at to me known to tar sbrr persxt s who executed the foregoing instTU nt and acioarsr>tdgr-t t~e sine. THIS INSTRUMENT WAS DRAFTED BY Y~` r^~ - - / i Ctt r i`~ t~ _ -~-L Wiscoiitin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: ST c~Ud11 INSPECTION REPORT /x 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)]. Z 9-- go 7 -I g Permit Holder's Name: TT ❑ City ❑ Village ❑ Town of: State Plan ID No.: 'GWI me CST BM Elev.: Insp. M Elev.: BM Description: Parcel Tax No.: bo f loo' i vA go" aX OP o - / 0(o3 TANK INFORMATION ELEVATION DATA n Ll SLF TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e Ic ( 0D0 Benchmar 2Z /00.22 !oo Dosing Alf f3Nl y V3 96-1-710/ Aer 'on Bldg. Sewer S&9 9c/s3 Holding St/ Ht Inlet 6•0-7 W-/S- TANK SETBACK INFORMATION 1h St/Ht Outlet (0.3 93 TANK TO P/ L WELL BLDG. Airintao-ke ROAD Dt Inlet eptlc /SDI r~ a„~ NA Dt Bottom Dosing NA Header / Man. -736 9a .gC/ Aerate n NA Dist. Pipe -7, Sa 7,p-7SI9a• Holding Bot. System c' 9/. PUMP/ SIPHON INFORMATION Final Grade 80 9S111X Manufacturer D and S iC,49tK 144 -0w le- aw 7~ 9S. ~7 Model Number r.DRA TD Lift I Loss Friction Syste TDH Ft Force in Length a. H Dist. To Well SOIL ABSORPTION SYSTEM BED Width Length No. Of Trenches PIT Inside Dia. Liq Depth DIMENSIONS 3 . DIMEN I SYSTEM TO P / L BLDG WELL LAKE / STREA LEACHING Manufacture . SETBACK INFORMATION Type O Model Number: System: -7D (oO A OR UNIT DISTRIBUTION SYSTEM Header / Mani old ~I Gk+nbr..r5 x Hole Size ~x Hole Spacing Vent To Air Intake Length Dia. q Length 6•Z5r Dia. '34of Spacing (0'b2 CIS) [v►F'~ll~a ,1c~w~~4~ 7 SOIL COVER x Pressure ystems Only xx Mound Or At-Grade Systems Only o 0S Depth Over n Depth Over xx De Bed /Trench Center 50~3~ Bed /Trench Ed Topsoil ❑ Yes E] No ❑ Yes E] No L COMMENTS: (Include code discrepancies, persons present, etc.) a? $(o A., b, v- 1,411S 0/^1e. TAG Wef!~ ~ not jnS-~ul~r~ a~ iNS~vw-h~rl, ( .~C (its- (pv l f v 13 f ~y~ C C.k4LW ber5 We,", r^.ae J %tis c~ Ue GahsWv-411M i Wz-&L,sa k9- tl fiG wa-. Bzee f,A7 p' Cl Plan /re ~isionreu5red? Yes C3 No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature ert. o. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: r~ 3 6C.ln=~ 611 a~ a ° n l vvlw SANITARY PERMIT APPLICATION 201eE. Washington Ave vision Vi sconsin 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 Permit Number eq 9gr36 The information you provide may be used by other oy4rpment agency prog(a s O ❑ Check it revision to previous application I r. [Privacy Law, s. 15.04 (1) (m)]. p► `Qi T 1 State Plan I.D. Number GOILA 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prope y Owner Name Property Location 114 1/4, S T , N, R AD& Propertwner's M iling Address Lot Number Block Number City, to Zip Code Phone Number Subdivision Nan)f or CSM Num r ( ) Y- II. T PE F B ILDING: (check one) ❑ State Owned ❑ !tyy Near st Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town of S III. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s) ao - ay. 30. .2 0. 7-6 Leo --I-/o 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 line A. Check box on line B, if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting 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 %Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill 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 1 2'w V1 9~2_:5' Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./' ch) Elevation Feet Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in strutted Tanks Tanks Septic Tank or Holding Tank /oor 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the dersigned, assume responsibility for in allation o e onsite sewage system shown on the attached plans. Plu ber' ame: (P t)~ Plum r' g ( St ps) MP/MPRSW No.: Business Phone Number: r `_5 lumbers Ac dress (Street, City, State Zip Code ,rJ IX. COUNTY / DE ARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing A nt Signature NOS mps roved Surcharge Fee) pp roved Owner Given Initial ~j Adverse Determination enejl X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R.11/96) 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. 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. 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 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. ,8,eo S;z~ - ,b? X"75 i '7eiesE -"'i're A ~c } j o ~I~,~ ,00 e y©, Wilcor~tsDepartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page / of __E La_:a 'aiicf Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY J Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNE PROPERTY LOC TION J - GOVT. LOT 1/4 1/4,S T N,R E (o PROPERTY OWNER': MAILING ADDRESS L BLO K # SUED. NAME OR CS w / CI TATE ) IP CODE PHONE NUMBER ❑CITY ❑ LLAG MOWN NEAREST ROAD New Construction Use pQ Residential / Number of bedrooms [ ] Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flows _ gpd Recommended design loading rate . ;r bed, gpd/ft2_~trench, gpd/ft2 Absorption area required _9eo bed, ft2 D trends, ft2 Maximum design loading rate bed, gpd/ft21~trench, gpd/ft2 Recommended infiltration surface elevation(s) 3 ft (as referred to site plan benchmark) Additional design / site considerations Parent material n - FI plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem 2S ❑U ®S ❑U [AS ❑U R1 S ❑U ❑S ®U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bound 3y Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch Ground_ elev. ft. - < 2- 91 Depth to limiting factor y~ Remarks: Boring # 4~... :iii ~ Ground elev. ft. Depth to limiting factor > ~3 Remarks: CST Name:-Please Print Phone: Address: , Signature: Date: CST Numb PROPERTY OWNER (36~i✓ SOIL DESCRIPTION REPORT Pages PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tnanch Ground elev. ' ft. - Depth to limiting factor Remarks: Boring # •.ia~;•i Ground.... / S elev. Depth to limiting factor Remarks: Boring # Ground Ce~lev.~ s ft. Depth to limiting factor > Remarks. Boring # Ground elev.,; d 77, Depth to limiting factor Remarks: SBD-8330(8.05/92) I ! I i IT I , --43 '000 I ! ' I I y i j i I i I i I dJ d i I i i i ~ , I f I - ~ I , L -L- 1.-_ _ - I - i..- - r- Ir _ - - - 90 _ --t \ - 1 I i. 1 , I , T- i + - I I i f i I 1 f ; I i , , r : I , I I I I I i I I r I I , ~ I I I i J I r i I I I I r , ! , I , , i i r , r ~ it JUN-30-97 MON 20:03 FAX NO. 16126311828 P.01 8~(A ..U,,ATION RA T pageLof x. . QSt-(t'F&x Nota 7671 Datep 7. PaGes► From I HR 83.09j' Wis. Adm. C017c To FCOUNT11.0.# CoJDe t. Co. . p~ rin size. Ptan must include, but ARC Phase N..+ Phone # 00 tii am % of slope, scale or Fax ' ' 3 1t 3 j q Fax a (Q 3 J~ fad•' REVIE DATE WED BY ATION PROP OWNS : t PROPERTY LOCATION GOVT. LOT - 1/4 IKS T ,N,R E (o Vyl ,CAI 7 i; P 0 PER7Y OW ER^.S . I ING ORRE59 L0 BLO K t SUBO. NAME OR CSM ' 1l'x' Ct /STATE 4 P CODE PHONE UMBER `QCITY O LlJ1G (MOWN NEAREST ROAD Kew Consttuction ' Ilse dQ Residential 1 Numbei ~f bedrpoms ~ Addition to existing building t j Replacement Public or commercial deScribe Code derived d 1y fiow. _ gpd Recommended design loading rate bed, gpolft2__Irench, gpolfiz Abstgllon area required;.940~bed,112 ~lre'ndh, Maximum design loading rate hed, gpd/ft2_,.~/,_vench, gpolft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material FI plain elevation, if applicable ft J17, 4". S: SuifaE le for'§ystem COtIVI:N1'IONAL MWN61 GROIi o`s=RESSURE AT•GRAt)£ SYSTEM IN ALL HOLCiNG TANK ®.S ❑ U Ca S b3 S Q t1 ®s o u Os ®u Os Z u U.=Unsuitable for s stem N 50.f p!*.SCRIPTION REPORT 4 De th; gominant Color Mottles Structure GP D/fi A < B~fing Horizon Texture Consistence E3otX>dary Roots G' In. , . f`iiunsell Qu: Color. Gr. Sz. Sh. Bed Tmrich Gr,und _ Ag N' .4 <q, 91 Depth to ' 'timi409 J u Eiemarks: Ala -ye- :~z 1 &5- .=2 ik 1 J- Is- Ground. ' • ! ~ I f Depth to il~itir•g. j ~ ~ iaclor i JUN-30-97 MON 20;05 FAX NO. 16126311828 P.02 PRQkkTYWNER fi~hr ~ it _ SOIL DESCRIPTION REPORT Pauq-,- /of GPD/ft Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounclary Roots in. Munsell Qu. Sz.Cor Color , Gr. Sz. Sh. Bed Trend 1-0 13,- 15/4, ~ r y ' Ground elev. ft _ s AW~ Depth to limiting factor Remarks: Boring # .7.4 Ground ~ y ~f ' ` ~ - 1' • ~ ~ t ~lev, Ar7 - ,T~ ft. •r Depth to limiting factor sn Remarks: Boring C'3 _ r Ground s r,✓Pu! elev. ft. ; Depth to iimiling factor Remarks: Boring # IN 'W. Ground - n : JUN-30-97 MON 20;06 FAX NO, 16126311828 P.03 264 1 f.......... . lq /w: III I i f I I i ~ ! ~ 1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/13UYER -1 d & 4' 0/- MAILING ADDRESS PROPERTY ADDRESS /om X, i~& I (location of septic system) Please obtain from the Planni Dept. CITY/STATE !574 O~ 4~ PROPERTY LOCATION 51~/ 1/49 1/4, Section/q30-/C/, T N-R W TOWN OF Sf -f ?S h ST. CROEK COUNTY, WI . SUBDIVISION _A__A~~7 /T7IS LOT NUMBER CERTHUDSURVEY MAP , VOLUME PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The 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/We, 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 County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 i4; 8 T C - 100 This application form is to be completed in full and signed by owner(s) of the property being developed. Any inadequacies w. only result in delays of the permit issuance. Should t] development be intended for resale by owner/ contractor, (sl house), then a second form should be retained and completed V the property is sold and submitted to this office with appropriate deed recording. owner of property ~5~,%/w~e'~~~~ Location of property kX 1/4 1/4, Sectioe3a")y,T N-R Township. ~5~ Mailing address Address of site ~r//~~~~f .00 Subdivision name A'7-yd~ *7115 Lot no. g other homes on property? Yes X No Previous owner of property Lee 671F',2P-5 ka,~ Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) W47-X Yes Volume and Page Number as recorded with the Regis of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND I NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, certified survey, if available, would be helpful so as to av• delays of the reviewing process. If the deed descript references to a Certified Survey Map, the Certified Survey shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to best of my (our) knowledge that I (we) am (are) the owner(s) of property described in this information form, by virtue of warranty deed recorded in the office of the County Register Deeds as Document No. , and that I (we) presen- own the proposed site for the sewage disposal system or I obtained an easement, to run the above described property, for construction of said system, and the same has been duly recorded the office of the County Register of Deeds as Document Si na ure of Ap plicant Co-Applicant / _ q/,~~/may 30 pate of Signature Date of Signature