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"59,9MA 4pa'rtme`n'iDofiln~ustry?R • 15. 214BPft'W"ATE S`EWAGF ?I(STEA 32011 County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 175673
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
BUTLER DUANE A & PATRICIA CADY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
004-1031-90-000
TANK INFORMATION ELEVATION DATA A9200332
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 3lv~/
Dosing I ` t
Aeratiert- Bldg. Sewer
Holding St/ Inlet
TANK SETBACK INFORMATION St/ Outlet
TANKTO P/L WELL BLDG. Aenttake ROAD Dt Inlet
Septic NA Dt Bottom Dosing NA / Man.%
Aera n NA Dist. Pipe
Holding Bot. System
PUMP/ SMSON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Inside Dia. Liquid Depth
DIMENSIONS DI EN I N
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING M acturer:
SETBACK CHAMBER
INFORMATION TypeO Mo elNum
System: OR UNIT
DISTRIBUTION SYSTEM
r / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length Dia. Spacing
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.) <Z' 15,
r,
_kAll
4
Gjz. , ~4,
1,j .
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C_ t
I ~a /G. Z4e, - +~T.3Z 3Z
Plan revision required? ❑ Yes ' ❑ No WTI/ U
se other side for additional information. 19 19 ~q
SBD-6710 (R 05191) Date Inspector's Signatur Cert. No.
i
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Ile
REPT131 CADY ST. CROIX COUNTY ZONING PAGE 1
09/08/92 15:19 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/ 9/92 AREA: MJ
.,Activity: A9200332 9/ 9/92 Type: MOUND Status: PENDING Constr:
Address: CADY 14.28.15.214B,SE,NE, CO. RD. N & 320TH
Parcel: 004-1031-90-000 Occ: Use:
Description: 175673
Applicant: BUTLER, DUANE A & PATRICIA Phone:
Owner: BUTLER, DUANE A & PATRICIA Phone:
Contractor: MENTER, JOSEPH J. Phone: (715)235-7341
Inspection Request Information.....
Requestor: MENTER, JOSEPH Phone:
Req Time: 11:09 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code TY d r• Q 1~
2. 1
STATE SANITARY PERMIT41
-Attach complete plans (to the county copy only) for the system, on paper not less than Qq ('8% x 11 inches in size. ~ffCheck~if revision to 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
-b 5- Zr 1/4 '/4, S 1 T-~9, N, R AS E (or W
P1;~ PE ~ OV~NER'SCM~A~ILING ADDRESS LOT # ' BLOCK #
CI STATE A_ ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
l50 ~j RA5 SSb~
NEAREST A
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE
, r n
ce
❑ Public 1 or 2 Fam. Dwelling-# of bedroom PAR L x UM R
III. BUILDING USE: (If building type is public, check all that apply) U Q c4- /031-90
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 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2. N Replacement 3. ❑ Replacement of 4-E] 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 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. 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
`-t 'i S 6 ~00 ®f 4 1 01" s Feet //i&?J Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank ~Yc /tvo r1d(l~osrcf~
Lift Pump Tank/Si hon Chamber we t & ^ w"lr TQ 4
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): ignature: (No Stamps) INVMPRSW N Business Phone Number:
a .re 1Ptuber's S 73 V
Plumber's Address (Street, City, State, Zip Code :
1 ).,o Co P., J•w 1-J10 a j i- e Wt S S
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Surcharge Fee Groundwater [Date issued Iss ' g Agent Signatur (No Stamps)
❑ )
Approved Owner Given Initial
Adverse Determination 7q,2
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
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 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.
1 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 (SB7 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 iq'ty 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 in line A. Complete iine 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 aid/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 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 .,y )e c,,+,nty; 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)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, cc DIVISION LABOR
BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/ LOT NO.: BILK. NO.: SUBDIVISION NAME:
SE1 NE 14 28 N /R 15 Cady I - - NA
COUNTY: MAILING ADDRESS:
St. Croix Duane Butler 320th St., WIlson, WI 54027
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER OLATION TESTS: .
~Residence 3 NA ❑New QReplace 6/13/92 NA
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: JIN-GROUNF)-P-RESSURE:ISYSTEM-IN-FILLIHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑sou Ds au osau osou 0S ME Mound
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: NA I Floodplain, indicate Floodplain elevation: NA
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-1 57 100.6 No 30 see attached p 3
2 36 102.0 No 16 4
B-
3 56 108.9 No 19 5
B-
4 66 109.2 No 36 similar to B-2: 0-36 sil, 36-66 massive sl w/ f2p R-Gy mots
B-
B-5 52 111.4 No 18 see attached p 6
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH
P-
P-
P- NA
P-
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.
SYSTEM ELEVATION
a
pits show extrem4y variable soils both "in terms of profile descriptions and estimate de~ths'to ground 'ater
r-~~ ~ ail r~ottling
as indcat~ed s -
r
onsite requested to confirm soils and determlp'.neibest structure,forimounid ~i e haw much sand_shduld be
beneath the rock fed?
see attached p 2 for plot plan
I ,
I - ,
- h;gh chroma..~nqttlg -.probably --residual, SS color's-from-4
- do ie csn€r-ms-,sails.-suitable far-mound-w/-
IN
colluv al soil de bsition - CST sil gritty w sand are probdblYbetter characterized as sl
p
in tal 51
1,x_ 7 ' ock 'bed mou Id_ on staked 108.3 con' S wpslope ledge of roc} bqd,_ use_
.w..___ . _
~ 1 3 t i t
_
i F } c [ E E € 1 ~ E
&
I, the undersigned, hereby certify that the soil tests reported thissAA m were made accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the I ' afn o~4)A 4 arjZ~ rrect t st of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Henry F. Grote P~ 0 6/30/92
ADDRESS: CO CERTIFICATION NUMBER: PHONE NUMBER (optional):
PO Box 57, Knapp, WI 54749-0057 3065 665-2681
Z~ CST SIGN T RE:
cc: Jansky
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
page 1 of 6
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395 r
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;
8. 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.
I
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures 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
fs - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand < - 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.
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Duane Butler - Mound
1
Location: SE 1/4, NE 1/4, Sec. 14, T 28 N, R 15 W
Town: Cady
County: St. Croix
Date: July 8, 1992
Owner: Duane Butler
Address: 320th St.
Wilson, WI 54027
Plumber: oseph Menter
Signature: gek' M
License # P 5658
Attachments: 6, 8-Plan Approval Application
State on-site (direct from Leroy Jansky)
115
page 1: cover
2: calculations
3: plot plan
4: system cross section
5: plan view, lateral detail
6: pump tank exit detail
7: pump curve
System Calculations
0.1 T 3
One family.residence 3 bedrooms
Loading rate 0•t° `0•S gallons/sq ft per d:L~
Depth to ground water > Z~• in (-p- "4r &ki & Depth to bedrock in
Cross slope %
r
Force main length 4 2~ ft of Z in
Manifold/header length r4t A ft of - in
Drainback gallons
Lateral length ft of in
Lateral elevation ft (bottom of pipe)
Lateral hole size in @ ~O° •O_ in ( S'.o ft) spacing
I ~9 holes/lateral, holes total
Lateral volume 14,E gallons
Total lateral discharge rate -LZ-"i-3 _ gpm @ ft head
Elevation difference 77_6r• 1° , ft
Friction loss 4 ~°g ft @ gpm
Total dynamic head 3 g ft
Pump/s:I~on 5 b gpm @ 3 ft of head
Manufacturer Model #
Dose volume gallons
Lift/siphon tank`" gallons
Septic tank gallons
Measurement pump on & off S, ~Z in
Height alarm from tank bottom ZI't~ in
Reserve capacity gallons
calcs page 2 of
i
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. GNSITE SE`SAGE SYSTEM
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APP J -
! A4:LR AN N IMI RELATIONS
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VENT CAP
`I"C.I. VEMT PIPE
WEATHER PROOF APPROVED LOCKING
> , JUMCTIOM BOX MAWHOLE COVER
25 F ROM ODOR
- ` ,
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WIMDOW OR FRESH tZ~
AIR INTAKE ` LAQ~L.
GRADE
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t
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PROVIDE
AIRTIGHT SEAL
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W/C.I. PIPE
ONTO SOLID SOIL
L x f~c~,.~ Conditiondiv ALARM EXTEWDIAIG 3'
~ ` l S, t L~. II Om
ONS6 E~ SYSTE PUMP
~ OFF
. BLOCK_
4..
I 0~.Jv dr.
t 1 ABOR A11lD HV Yla
orTARYMEN Io~GJ5~fi'~ ,Elf N UI INGS .e
!ON OF
SEE CORRE N
~ ~1a
A 2-
C~
HEAD/ W
115 _ _
~0
CAPACITY _ 34
32 105
i
CURVE 30 5
28
9°
i
26 +85
EFFLUENT 24 B0 ~ N I \ , ' 1-- MODELI i
C f75 MODEL 189
and Q 22 165
DEWATER/NG = 70 i
V 20 --65--
z 18 so
0
J 16 55+ rl I i
50 MODEL
G 163 MODEL
I-. 14 05 188
12 40-
35 -
10 MODEL
30 137, 139 - MODEL
185
SEWAGE and 6 25
DEWATER/NG 6 -20
i MODEL
MODEL 161
15
4 97/
10
x MODEL
I- U. 5 53, 55,
2 57, 59
0
GALLONS 10 20 30 40 50 60 70 80 90 1 110
24 ~
75 LITERS 0 80 160 240 320 400
22 FLOW PER MINUTE
70
20 65
18 so- MODEL
Q 295
W 55
S 16 i I I
ABLE DISTRIBUTING CO,, INC.
Q 11 MODEL
z 294 144 W. WASHINGTON ST.
1x 145
40- I P. O. BOX 1367
Q I MODEL
35 ! I i WAUSAU, WISCONSIN 64"1
293 '
1- 10
30 MODEL I_ - 715 - 842-92SG
f" 8 i 284 j
i
25 - - --1
MODEL I I
6 20--___ - ' 282
15
10 MODEL
4 OELLE~P O.
r2 5 267, 268
° 3280 Old Millers Lane
GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 160 190 P.O. Box 16347
Louisville, Kentucky 40216
LITERS 0 80 160 240 320 400 480 560 640 720 (502) 778-2731
FLOW PER MINUTE ~ ~ 0
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER_ u r~, g By 7-4e r
ADDRESS 3-2_0 TPk FIRE NUMBER
CITY/STATE -zip
PROPERTY LOCATION.'se- 1/4,k&1/4, SECTION /q , Telt N-R__4_Ck_W
TOWN OF g d , St. Croix County,
SUBDIVISION , 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 a 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 Co. Zoning Officer within
30 days of the three year expiration date.
SIGNED. L',C~ i
DATE: 7
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
S T C - 100
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 1)6. jakj e.. & 7-,P C-
Location of propertyj2E-1/4N 2~' 1/4, Section , 12LN-R /Is W
Township
P1 4
Mailing address E
Address of site
Subdivision name Lot no.
Other homes on property? yes No
Previous owner of property
Total size of parcel /0 ~-C
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes Y_No
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & 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 County Register of deeds as Document
No.
zaz_,~
Signature of applicant Co-applicant
&7- F ? d--..o
Date of Signature Date of Signature
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