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HomeMy WebLinkAbout038-1082-70-100 1 s it STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER "r~ ADDRESS SUBDIVISION / CSM# LOT # SECTION. Tom/ N-R ,LS W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN / OF S STEM J~OUsE k~ /Gtr r ~t le Sam/ 5li o a dos INDI ATE NORTH ARROW Provide setback and elevation information on rev rse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM.4;~ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well- House Other Pump: Manufacturer ModelP Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches .42 Distance & Direction to nearest prop. line: Setback from: well: HouseOther ELEVATIONS Building Sewer fig ST Inlet. /a95" ST outlet ~2- PC inlet PC bottom Pump Off Header/Manifold Bottom of system gym/ Existing Grade Final grade /Cz%~~~ DATE OF INSTALLATION: PLUMBER ON JOB: y ~U- LICENSE NUMBER: INSPECTOR:- 3/93 jt : ST. CROIX COUNTY WISCONSIN - ZONING OFFICE r r n n p n r n■ „o■„6 ST. CROIX COUNTY GOVERNMENT CENTER 1 1101 Carmichael Road s Hudson, WI 54016-7710 (715) 386-4680 i November 30, 1994 Ms. Becky Hartman Hartman Homes Inc. P.O. Box 326 Somerset, Wisconsin 54025 RE: Septic Inspection Dear Ms. Hartman: An inspection of the septic system serving the Tim Germain property was conducted on October 20, 1994. This property is located in the NE; of the SE; of Section 20, T31N-R18W, Lot 1, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. Should you have any questions, please feel free to contact this office. Sincerely, Mary J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz l l ~ [ ~ 1 ~t~uf WiscGnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ` Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan o.: GERMAIN, TIM X _ _ _ CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax o } TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ! _y Benchmark Dosing Aeration Bldg. Sewer 7x 116,03 Holding St/Ht Inlet 5 TANK SETBACK INFORMATION St/ Ht Outlet 7 ~oy,a TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Air I Septic 3o+_ / lVWO)OL /0 ' W601 NA Dt Bottom Dosing NA Header/ Man. 4,75- Aeration NA Dist. Pipe 6.84 97A Y Holding Bot. System 7(- 97m vV PUMP/ SIPHON INFORMATION Final Grade c/, /o o, Z$ Manufacturer Demand Model Number GPM TDH Lift Loss System TDH Ft ead Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /0 Sy DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of nA,, CHAMBER , Model Number: System: D~ 62 aD ' 168 /9- OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing i 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. 7)scb_ P5" LOCATION: STAR PRAIRIE 2q,31.18W,NE,SE,LOT 1,CTH C 4Plan revision requirB~S ❑ Yes ❑ No 1,9 1 Use other side for additional information. JO' SBD-6710 (R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH a SANITARY PERMIT NUMBER: i lw. SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than p~/ ~ 8% x 11 inches in size. El A.Dif vvision to pWrevious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWN PROPERTY LOCATION t/4, S T , N, R E (Or 5Z & t/a PROPERTY OWNER'S MAILING ADDRESS LOT # / BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER -171 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned, a ❑ VILLAGE ❑ Public 1 or 2 Fam. Dwelling of bedrooms P12 TOWN OFZ ja"."z ARCELTAX N MBER(S) III. BUILDING USE: (If building type is public, check all that apply) '70 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 110 Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 22 ❑ In-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 3 -C Feet Feet VII. TANK CAPACITY Site in allons Total if of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber F-1 F-1 1-1 [1 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installat' n of the onsite sewage system shown on the attached plans. Plumber' Name rinty ' Plumbe 's Si natu MP/MPRSW No.: Business Phone Number: Plu ber's ddress (Street, City, State, Zip Cod _,4-ZeZe Z4~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A ignntttre No mps) SR rharge Fee) 4- Approved ❑ Owner Given initial ` Adverse Determination VU X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety a 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, 60B-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. 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) -5ACC 00 6,2 ~ ~ ~O SCE c . ~ dq dl1~,t'sc,~ ,~s'9 110 y ~ 7s/ c~ w '.1 PAG C o r Y . t 114611, All Weil 4A11 96641voll" Pipe AP 404 Vow Cq f. rrw....• 1a4Aau•o t' i0• a` A"** 11~ ~ C••1 IIM i.Il..l'o~•.• wM pits u- lot 141 or $romgns C•. tk d ' ' Ott, ;y,M•NI~ • ~IgUtl•1{~ • • fits Too / A' Allr•1o1• ' ~•w•It► PIP• • P•rlau•• PIP• 64101r • ~C•.Nlal lrwl••il•t AI tl•u•* 01 iir,l•• y• Y` 601 rILL' . ©IMIDUTIO►,1 PIrC APPRO`Ir r S'IN pICTIC COV 2"WI~GGREWF. AT1-Ri►,t OR I' OF vrg euG,~pY'Yt-t,/Z A.GGRCGHTC IJAV. of: t ' plSTitl4UYlO1J PIpt.TU DC AT 4CA><7 _ IWCHES BCLOw OR}G"IWAI. •;rApC AUU AT LEhsTLO IWC.HCL BUT 1.10 MORC THAW 42 ILICIiEs Du.Ow r►NAI.. GtIAOC 'W'mUM DEPTH OF C-ACAVATIOP FXoM OWWAL 6K)\vE w1Li. e,E - IucNCS tVHIMVM OEPni OF EACAVATION rAOM, 0~I4INgL C+RADE WILL. BC ---~L~. INGHCS SiGIJf`~: Sir,CUSC UUMDCII: OAT C , ' t; 10 1 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY., C DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS fC%/ (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHI UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: zclke~lil ze2 IT_.~?INIR14 2~~~~.'Aoea /,.4 1 . e__ 41-11-0-07 UNT : / MAILING ADDRESS: vl~ ~-G p~ G BPr S' d~ USE DATES OBSERVATIONS MADE 6 NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence - New ❑Replace S RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUND PRESSURE:SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) F0 S DU 54S DU GAS DU D S U D S ®U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: G[(~ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ee o 5 s~- B-,2 'K B-s a yr d17 Sir may- Or, B- PERCOLATION TESTS c TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P P- < 5 G^ P_ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. xe '00, 'ZZ_ / SYSTEM ELEVATION ~Mz y 1 _ f a A ~ ~or . a _ p o << CO 41, o 49 C, I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER. ONE NUMBER (optional): CST SIGN U E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6,03095 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use suction must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 6. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Taxturaa Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well is - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand "C - Less Than •1 - Loam Bn - Brown 'sit - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. Ili STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER i%.za .asp j] ~v c /z r AL&ILING ADDRESS cl> C_ So s. ~o s>'o z s PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION N'C" 1/4, 1/4, Section 2_0 T 3 N-R__:~f_W TOWN OF 5470C ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME 1O0 r , PAGE -7/' , 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 co lete and returned to the St. Croix County Zoning Officer within 30 days of the three year expiratio at SIGNED: . DATE: 7`- St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 CERTIFIED SuKyzz nAr - 'L,ocated in part of the SEA; of the NE; and in' part of the NE h of the SE; all in Section 20, Township 31 North, Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin. NE Corner of LEGEND OWNER Section 20 m 0 1 " Iron pipe set, Urban Germain c weighing 1.68lb3/Iln. ft. 2034 C.T.H. "C" c Somerset, WI 54025 _ • 1" Iron pips found !a County Section Monument - 0 i= Aluminum Cap Found 12,10 k N I d r` ,we e.. .1 IWO 4- to% p m ^t ~j m U z C. v o ,N Es o ' 3s 4 WIS. L -i: ~JyC~d062StG03~4+3~• dg -m IT i a SCALE IN FEET 1 n ~A1 57, 0 50 1,00 bAh~a9 ~ . ~ APPROVED 0\ S6~ LOT 2 m AUG 2 2 1991 85,222 sq. Ft. ST. Mom COUNTY w m AND ZONING COMMrME 0~~ 1.96 Acres ; d 1.95• 0~ 00, . E7 Corner of spy LOT 1 Section 20 r, 88,257 Sq. Ft. ' Q \a ' 2.03 Acres 0 401003'44"E 1.42' s o, m 0,19 m n o\a ;~l 16N ' \Ded sod: o0 CPPo - ~ 00,1`"0~ / SE C~~'Al OF 5~c~aJ as CURVE UA•1'A CURVE LOT RADIUS CENTRAL CHORD CHORD ARC TANGENT TANGENT 1 NO. NO. LENGTH ANGLE BEARING LENGTH LENGTH BEARING BEARING 1 - 2 1186.28' 14005'30'1 N68017'2811E 291.03' 291.76' N6101414311E N75020'1311E 1 1186.18' 50011.2511 N63°45125.5"E 103.98' 104.011 2 1186.28' 9004105" N70048110.5"E 187.55' 187.75' SURVEYOR'S'.CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby certify that by the direction of Urban Germain, I have surveyed, described.and mapped the land parcel which is represented by this Certified Survey Map; that the exterior boundary of the land parcel surveyed and mapped is described as follows: A parcel of land located in part of the SEh of the NEh and in part of-the NEh of the SEh,all in Section 20, T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin; further described as follows: Beginning at the Eh corner of said Section 20; thence N00037'16"E, along the east line of the NE4 of, said section, 378.76 feet; thence S61014'43"W, 645.49 feet; thence S24011'G9"E, 296.54 feet to the northerly right-of-way of County Trunk Highway "C"; thence N61014143"E, along said northerly right-of-way, 193.79 feet to the point of curvature of a 1186.28 foot radius curve concave southeasterly, whose central angle measures 14005'30", whose chord bears N68017128"E and measures 291.03 feet; thence northeast- erly, along the arc of said curve and said northerly right-of-way, 291.76 feet to the east line of the SEh of said section; thence N01003144"E, along said east line of the SEh, 1.42 feet to the point of beginning. Above described parcel is subject to all easements of record. I also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 of the' Wisconsin Statutes and the Land Subdivision Ordinance of the County of St. Croix in surveying and mapping same. e 5 o Co Allen C. Nyhag n Date • , Al.L.-N C. IN A; ..~~lcr r , w VOLUME 8 PAGE 2393 a S T C - 100 + I This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property AA 1/4 SF 1/4, Section 20 , T 3/ N-R_!Z W Township Mailing address 703,5 Gd eel Address of site y-/ Subdivision name Lot no. Other homes on property? Yes No / Previous owner of property (fr:~7&~i'~ Total size of property p S Total size of parcel Date parcel was created ?erg, ZZ 1!/171 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ~Q No Volume Ov and Page Number 7- as recorded with the Register DaG. #4f1C3o of Deeds. --------~~!+~--U`-'~-- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER 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 Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 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 described 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 sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. c. Sit tifrJof Applicant Co-Applicant 1A ~ - li DaatCee of Signature Date of Signature