HomeMy WebLinkAbout032-2053-20-000
Parcel 032-2053-20-000 04/27/2006 08:01 AM
PAGE 1OF1
Alt. Parcel M 15.30.19.698F 032 - TOWN OF SOMERSET
Current XJ ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
TIMOTHY D KOHLS O - KOHLS, TIMOTHY D
1558 63RD ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1558 63RD ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.030 Plat: N/A-NOT AVAILABLE
SEC 15 T30N R1 9W 3.03A IN SW NW LOT 4 Block/Condo Bldg:
CSM VOL 4/963 (EZ-U-1141/337) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
15-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
03/05/2001 639787 1596/298 QC
07/23/1997 1056/512 WD
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07123/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.030 48,100 104,800 152,900 NO
Totals for 2006:
General Property 3.030 48,100 104,800 152,900
Woodland 0.000 0 0
Totals for 2005:
General Property 3.030 48,100 104,800 152,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
A IN r u r N■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 540 1 6-771 0
(715) 386-4680
February 16, 1994
Heartman Homes
P.O. Box 326
Somerset, WI 54025
To Whom It May Concern:
An inspection of the septic system for the Tim and Steffanie Kr'
property in Document No. 510899, Vol. 1056 at page 513, Lot 4,
located in the SW; of the NW; of Section 15, T30N-R19W, Town of
Somerset was conducted on January 12, 1994.
At the time of the inspection this septic system was found to be
code compliant for a three bedroom home.
Should you have any questions, please feel free to contact this
office.
i erely'
James Thompson
Assistant Zoning Administrator
js
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER T rI.Y)
ADDRESS
SUBDIVISION / CSMI LOT
SECTION T N-RA-W, Town of ~/r
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f
T y a,
4 ~ ~ .rte
F
s-
i
INDICATE FORTH AR120td
Provide setback and elevation informant ion on reverse of this form-
t'rovi diMCI,11 .o,~. to center o! -'ept,,c tang: manljol_e coves. -
i
r ~J
t' G~
It dle ~ r
I-le
17
c G
L9AAWrjAV artMc FJy, 15.30. 19 1'KIV TE EVyA8g SYSTE ETA LOT ounty:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermit o.:
Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ft.:
lev.: Insp. BM E ev.: > BM Description: Parcel Tax No.:
X!001 40 1 16 ~1 10 037-2051-20-300 -1
TANK INFORMATION ELEVATION DATA A9400003
y,
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Sr'_ Benchmark'
Dosi ng ,5 /dam
Aeration Bldg. Sewer 2pq
Holding St/ Ht Inlet (o
TANK SETBACK INFORMATION St/ Ht Outlet 99. _V
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
Air l
Septic S S~~ NA Dt Bottom
Dosin NA Header/Man.
Aeration A Dist. Pipe
y '
i
Holeli Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Ma u actur Demand T.,oa' S,T_
ra , 3, ZS" 103.6,9'
Number G
TDH Lift Frictio ys t
\ H
ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Tr riches No. Of Pits Inside Dia. Li d Depth
DIMENSIONS If DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING `e`'
SETBACK
INFORMATION Type Of 0-aivL 1A_ CHAMBER n Model Number:
System: A'C_y/ J'J
DISTRIBUTION SYSTEM
Header Pt=I=IAlC ~i Distribution Pipe(s) , __7 cing Vent To Air Intake
Length Dia -Y-/ Length Dia. Spacing _ _Z~ t"
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onl
rBed,t Over Depth Over xx Depth Of ed / Sodded xx Mulched
enter Bed /i1 fledges Topsoil ❑ Yes ❑ No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION. SOMERSET 15.30.19.6981ISW NW 63RD STREET,
r s~\ `I~GC• ° TT C
c~C~r r
n?
C3)
Kfilan re~uonkregirke.6.Jf 1 [C'o
Use other side for additional information. - 1 -
SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
DILHR SANITARY PERMIT APPLICATION
,
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
J1. C,
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ IC
8'h x 11 inches in size. check if revislo previous application
-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
,S'' '/4 0 14, S S T50, N, R E (or)
PROPERTY OWNER'S MAILING ADDRESS LOT # L_I BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION ~A7 OR CSM NUMBER
e A';'c td 1 1 i
L:I 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE : NEAREST ROAD
:Sui~Pr ,
❑ Public ij] 1 or 2 Fam. Dwelling,# of bedrooms PARCEL NUMBER(5) -a 0 TAX Ill. BUILDING USE: (If building type is public, check Z11 that apply) f O
5 D
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~ New 2.E1 Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # _ Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 220 In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 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
f~ REO IRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
/ JlFeet YM-Feet
CAPACITY
VII. TANK Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 100o -T I -Y_ 147e-IFE El El
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, 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) MP/MPRSW No.: Business Phone Number:
;~q '-dj y ~ I
-3 21g ),2 74 L~
Plu is Address (Street, City, State, Zip Code):
6 `S~ 0
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanity Permit Fee (Includes Groundwater Date Issued Issuing Agent Signatur (No S m.P~) 17 -J, Surcharge Fee)
Approved ❑ Owner Given Initial iV
Adverse Determination /_/0
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (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 sanitary permit may be renewed before the expiration 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 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 & Buildings Division, 608-266-3815.
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.
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.
VII. 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.
Vlll. 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% x 11 inches must be submitted to the county. They
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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
PLOT PLANq ao 6
PROJEC s rT, DDRESS
1 /4J~~ 1 /4/S/7 /T~~ N/R/~' W TOWN COUNTY _ G of
MPRS Byron Bird Jr. 3318 DATE - -
BEDROOM--3 CLASS PERC_ L CONVENTI NAL -GR PRESSURE
CONVEN ONAL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA 4?42- PERC RATE J BED SIZE fa x®
IIIL !
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark 70J-f
0 Borehole Q Well Scale Feet
O Perc Hole System Elevation ~2 ys'
Vent
12"
Grndp
TYPAR COVERING
2"
12" 3' 4 60 0 3' 3 Q
Sewer Rock
1 16- 12' /4
b
o2
157,
1 1 - 3 ~~3 i1
a
~ Y
r
01
/ `J Jc~/ /T ✓ .
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of ,3
Labor and Human Relations
Division if Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY f
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 OWNER: PROPERTY LOCATION
W V "k C a, k r IS C) r) GOVT. LOTS v,) 1/44)A)1/4,S/;5T 30 N,R J F &(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
Q A4 _ o0 -r- Z~. ~Z Nr4 N.4
CITY STAT ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE 5 ?TOWN NEAREST ROAD
L i (/)I• for! (2/5) JW-35.E8 S I r-4 . vLa.
[ New Construction Use [ Residential / Number of bedrooms .3 [ J Addition to existing building
] Replacement [ ] Public or commercial describe
Code derived daily flow $~o gpd Recommended design loading rate 46' bed, gpd/ft2 trench, gpd/ft2
Absorption area required 00 bed, ft2 96b trench, 112 Maximum design loading rate ..5 bed, gpd/ft2 r trench, gpd/ft2
Fecemmended infiltration surface elevation(s) 4 ~S ft (as referred to site plan benchmark)
Additional design / site considerations r''/ ►d
Parent material m.~w •rts1A Flood plain elevation, if applicable ,N'Y-1 ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 54 S ❑ U -aS ❑ U aS ❑ U Ea'S ❑ U ❑ S a ❑ S G;~U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
0-7 2)/ E > a m r ryl 4yZ_ G'D a-~ S
2 7 27 5 YK `~/'t- n 0yv ~0__ m r M ~o le 5 ~ b
Ground 7.$ 7 . S /29/ /S 4 s ri 5'
elev.oo
/0
Z' ft - 6 0 jv e L° s a S5 7
XtZ Depth to
limiting
factor
Ftemarks:
Boring # .41101
T-L
iK/
- a~
a is
21-9S 75' i s
Ground
I
elev. r
3
/00 p ft des CR Ix
;e~ 6T Depth to
limiting _ z S O S yw✓
factor
Remarks:
CST Name:-Please Print / Phone:
(O S7- E / 5 - Z SF~o - Zpo
Address:
Signature: y Date: CST Number:
of ,~"-y3 CDSy,~W zz9
I
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2 of'-_3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxxiary Roots GPD/ft
in. Munsell ()U. Sz. Cont. Color Gr. Sz. Sh. Bed Tr2r
C, CD a
«3' D
and r m GcD 5
-2 752/
iij
Ground 7-87 6 sl /2
elev8;
OJ= ft.
Depth to
limiting
factor
r~
Remarks:
Boring # 17 /0 M&
vV ~
I
?_g 5 Z of vr1 YYL i `i
1114
I
/r-1-Ground
2-15.7-9 1-0 e, Y-
elev. S
~ e v -ft.
Depth to
limiting
factor
w
77 I
I
Remarks:
Boring #
►n 0~ ~ ~J ark ~ is
I
N ,
3 cJ ' .
5 cs~
D
Ground
elev. 3 41
F 5 / a n~ ~o ~'1' , v
Cig -5.
Depth to
limiting
factor
Remarks:
Boring #
4:i ZZ 0-1
8
round
G
elev. ~
/oo ~ft.
Depth to
limiting
factor
yAz ~
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 99&-N. Shore Drive
C.S.T. 2298 ( r4rd d ®p» n A QA n.S o *2 New Richmond, WI 54017
MPRSW-3254 5 C'j Yi+ N W y+ 5 5 1- 30 A) - /?)'7 ~ (715) 246-6200
40 W n ~ d ~~'Y1 Q.►^S
N'
,Sao
r3m..-~,~al° ~h
ur~Art~~,,, PA:7 A q
, tJ
5 166
174 ' 1 18'
1 0 'V )81
ft? 76 '
1 ~ .v~0 z.s
o'
S3-b
17
s.c.
nL+EOD 65 S-
CA IAI&pl CERTIFIED SURVEY MAP of D.•d, V
WILLARD JOHNSON l fr. GOi~ county,
l WISCMIA 0
Part of the Southwest 1/4 of the Northwest 1/4 of Section 15, Townsh 6
30 North, Range IV West, Town of Somerset, St. Croix County, Wisconsin.
o Indicates 1" x,24" iron pipe weighing 1.13 lbs/ft. set.
Om
A/00 O:3 OO E" 60. O n/fe 3548E" 'x-08 86'V / G 5.86 z4 3 O
33. O~
^o 2F~6.00' 2 b7• ~0 /04.
Sao N~o N
~ s W
O
O LOT / U( GOT O I 0 00
~k w m N
0 0CD °
o ,o ~m o
0 ul 0 0 w G OT 0 9 I o 1
6 10
A0, 7 7
33.03 X3.03 p_ J ; Gz _8 6
a 24-x• / N
I,1 33. 3 ir=1 .00 2C~-7SC) yc X46'
TOW /V .4 OAlC
J~OI N
VO \ GOT / 3. OZ AC. z. 0a A C. EXC. . O. W.
GO77'2 3.0/ AC. Z.8/ AC. EX C. /F'. O. W. 0
G OT :5. / 4C, z .4MIM A C. Exc. R. O, W
GOT¢ 3.03 AC. Z•4-6 AC• EXC. W. 0
=CALF" / = 200 0
0
I O
T30IV,
ION: SO(JTlyG //VE SEC. /S.
DESCRI PT
That certain parcel of land located in the Southwest 1/4 of the Northwest 1/4 of Section 15,
Township 30 North, Range T9 West, Town of Sommerset, St. Croix County, Wisconsin, more fully
described as follows;
Commencing at the Southwest corner of said Section 15, thence N 89° 20' 431, E 1311.39' along
the South line of said Section 15; thence N 00° 00' 0011 E 2744.20' to the POINT OF BEGINNING
of the parcel to be herein described; thence go S 87° 44' 45" W 1047.46' along the centerline
of a Town Road; thence leaving said centerline go N 00° 03' 5311 E 496.60'; thence
N 880 35' 48" E 637.50'• thence N 00° 03' 00" E 60.001; thence N 880 35' 48'1 E 408.86';
thence S 000 00' 00" E 541.10' along the centerline of a Town Road to the POINT OF BEGINNING,
containing 12.25 acres, more or less, being subject to easement over the Southerly 33' thereof
and the Easterly 33' thereof, for Town Road purposes.
(For purposes of this description, all bearings are referenced to the South line of Section 15,
Township 30 North, Range )9 West, assumed N 89° 20' 43" E.)
State of Wisconsin)
St. Croix County)
I, James L. Murphy, Registered Land Surveyor, do hereby certify that by direction of the
Owner, Willard Johnson, I have surveyed and divided the lands shown hereon in acli
with official records, Chapter 236 of Wisconsin Statutes and the Ordinances o~i~~ tt~(51.P4. %i
County; and that the above map and description are a true and correct repre,. 'on there
I JAMES L.
Dated: 21 August 1979 APPROV MURPHY
Vol. 4 Page 963 ~0,() S- 1 0 4 2
Certified Survey Maps James L. Murphy RIVER FALLS, O
St. Croix County, Wisconsin Registered Land SurveyofJ,,'J'j . Wisc.
ST. CROIX CUUi,T"i
COMPREHENSIVE PARKS PLANNING Vol. 4 Page 9F,3 [A~~ CJ
AND ZONING COMMIIIEE
!!!!!lIll rlllllllllll~~1~\\\\
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER -7/-,of i3-✓D .5 le-
d
MAILING ADDRESS Zf -06 tr tA
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE ~-L' tts r 4~
PROPERTY LOCATION 1/4, 1/4, Section S , T N-R_ W
TOWN OF So-h Y 7 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME /vi"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: l aC~
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
APPLICATION FOR SANITARY PERHIT
8TC-100
This application form is to be coraplatod in full and signed by the owner(s) of
the property being developed,.. Any inadoquacies will. only result in delays of
the pzrmlt Issuance. .Should this development be intended for resale by
ovnat/contractor,(apae houoe), then a second form should be retained and
cos+pleted when the property Is sold and submitted to this office with the
appropriate deed recording.'
Owner of property 7i II /wi~ Fes- .E~c~~L$•
Location of property ,L 114 N401/4, Section
Township
Kalllnq address
ti.
Address of site
lubdivlslon haste .
Lot number _ .7
Pcevlous owner of property t-j - d c. -+C -o'
Total size of parcel 19rie
Data Patcel was created /7u l 17
Are all corners and lot lines Identifiable? Yes No
Is this property being developed for resale Capee house)? Yes f(a
VolUAK and Page Humber S ~ as recorded with the Reglstet of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOLIIHCt
A VARRMTY DYICD which Includes a DOCUHIHT HUHBIR, VOLU1{¢ 114D PAOL NLrXBZR, and
the 89XL OF THE MISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certlfled Survey Hap, the Cartlfled survey
Hap shall also be required.
---------------------------------------------------------7---------------------
PROPERTY OWNER CERTIFICXTIOH
I(Vs) cartlfy that all statements on this form are true to the best of sty (our)
knowledge) that I (we) am (are) the owner(s) of the property described in
this Intotmation form, by virtue of a werrant eed rec rded In the Office of
the County Register of Deeds as Document Ho, h 10 and that I (Ye)
Presently own the propoacd site for the sewage dlaposal,ayatcm (or I (we) have
obtained an easement, to run with the above described property, for the
construction of Said nyatem, and the same has bat ul r e rded in the 01flca
of the County Re I or of Deeds, as Document No. ®
s2
signature of Owner Signature of Co-Owner (It Applicable)
_ '-y ~
Date of Signature Data of Signature
#546 P13i
PGtEP-142 3 FOR Al(:0s; ING w"A ~I
WARRAr I"Y UEEi,-
13 RE W R'S OFFICE
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C~~mo °,enne xi~n6n tPt ~nyrapsaity BnovId be !a~~d ~r,rl+$+ btltr~ ~rAturoe,
WARRANTY pUl~l3 Gn a'1i~t5i651 tv .sit, t~,r7. ~cx F02u3, G ee~~ e;3j.
STAYS
~i
FARFfi ' . - 14f32