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HomeMy WebLinkAbout161-1059-95-000 oy0 ~vn d r~ 0 d f O C, t9 r1 '7 v (D N v (D I i 3 # ~ Uj ^ 3 o o=i o=i v O ° A < w rn `C n, m 7 O O W ((D CC 00 N d a d 0 N Co (D IV O ~ ZF M o o C) a-)~ o Ul CD ;!L y = 2 O C N A C C y a a v cn (D D C P. o (4 cn o N CL 0 N W i cn --j CD rz O jv Z rt H C a O O (T fD rd C. rn O !•i (D (y rt CD CD S I cnn r- cn rt rt [n ri CrJ ((n co co 00 F O rD v cn c O r• ~J m p a rt rt o Z z O O O -0 z o H o N 0 s !mil ~ t^j x n 'moo r tJ N f~/1 = O m W ~j (D W C-- o. m O Nn Colo, CD N O CD m j Sp ~y p m cD N H m N o 3 m y Q a N 1 - ° L' o D a j o t~ I o d o CD i CD N C` ~ v U, N C H c CD N d1 r• N ty w m n. Z z o 3 C. I CsJ z (D -i V7 Vi ° Z D (n o _A ~j .n. O N Q A Z O G~ F-n O M O o N rt :3 _ ~ x o R1 v co w w a0 z CA r-O z No p N z (D A O D CL 0 S T v ~ z a 0 CD N fi Z A N V N O O i I a O b (D 6Q A O 0 ti Oo p (D ~a L Parcel 161-1059-95-000 06/23/2006 03:49 PM PAGE 1 OF 1 Alt. Parcel 13.29.20.526A 161 - VILLAGE OF NORTH HUDSON Current X 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 O - VILLAGE OF NORTH HUDSON VILLAGE OF NORTH HUDSON 400 7TH ST N HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 715 GALAHAD RD N SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.490 Plat: 0055-VIL OF N H ASSESSORS PLAT OL 85 EXC S 920'3.49A VIL NH FERRY Block/Condo Bldg: LANDING PARK Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-29N-20W Notes: Parcel History: Date Doc # Vol/Page Type 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/27/1985 Description Class Acres Land Improve Total State Reason OTHER X4 3.490 0 0 0 NO Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER V c op D TOWNSHIP SEC. Z T N-R D W ADDRESS A V ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH;R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM GALAN~d 1 T~5 /vU/tTN /~1 'Rv/11 ; Y L IN6 ~ X i SL VEti7 S7.C!< a i 80, 1 aVE2 )boy i~ sov-' • P2bnr2TY L=n.t iAVILL2bY~ F~YTfT2,/G G2/>'Y L n2T., V l_XLCTZ ni! Vn Ar ~"c. Z INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 144 J -0A,,, 1-, &c )AJs«2o,.1 L-a'6 Elevation of vertical reference point: Proposed slope at site: p I SEPTIC TANK: Manufacturer: Liquid Capacity: 1,9 jr(~rf-o7~ Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: C~ 3 Number of feet from nearest Road: Front 10 Side 0 Rear, feet From nearest property line Front,O Side,O Rear, feet Number of feet from: well, building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Z(' Trench: Width: T 9_ Length: r~ Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,® ht. Number of feet from well: o Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: r Inspector: Dated: v{~ Plumber on job: i License Number: 3/84:mj DEPARTI'I ENT OF INDUSTRY, INSPECTION REPORT FOR 31 gullDING DIVISION UABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969 MADISON, WI 53707 State 51 I D-N~'«~' CONVENTIONAL ❑ALTERNATIVE II If assignedI L __J Holding Tank El In-Ground Pressure ❑ Mound 85-02226_ COMMERCIAL INSPECTION OATS I NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER. /~1 yu v j Village of N. Hudson 7th St. N. Hudson, WI i I (a REF. PT. FILE V.'. CST REF PT. ELEV BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN I NE NE, Section 14, T29N-R20W, Village of N. Hudson San tay Pem Number ~Nanie of Plumber. MP/MPRSW No Cou~ty - Gary Zappa 3300 St. Croix 64938 i SEPTIC TANK/HOLDING TANK: MANUFACTURER . LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELE V.. PRWARN OV IIDEpLABEL PLOCKING ROVIDED OVER YES LINO DYES LINO NUMBER OF ROAD PROPERTY WELL BUILDING IVENT OFRESH' BEDDING. IVINT DIA.. VENT MATL HIGH WATER LINE- AIR I/NLEJ YES ❑NO ~y p% © ALARM FEET FROM DYES LINO NEAREST A / DOSING CHAMBER: WARNING LABEL LOCKING COVER MANUFACTURER. BEDDING. LIQUID CAPACIiy PUMP MODEL- PUMP; SIPHON MANUFACTURER PROVIDED. PROVIDED: EYES LINO EYES LINO DYES LINO PUMP AND CONTROLS OPERATIONAL. PROPERTY WELL BUILDING VENT TO FRESH GALLONS PER CYCLE: NUMBER OF LINE LAIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYES LINONEAREST LF (F{ DInMFTER MATERIAL AND MARKING I SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE i or excavation. (If soil can be rolled into a~ construction shall cease until MAIN the soil is dry enough to continue.) /a1 L` Q CONVENTIONAL SYSTEM: 7 ✓ NSIUE DIA SPITS unulD DEPTH WIDTH +LENGTH NO. OF DISTR. PIPE SPACING. COVER . BED/TRENCH TRENCHES n.iTERIAL: PIT DIMENSIONS j I (iy ° H71 PROPERTY WELL. BUILDING. VENT TO FRESH GRAVEL. DEPTH FILL DEPTH DISTH i IPF DISTR PIPE DISTR. PIPE MATERIAL. FI SST R. % UMBER OF -TINE _ AIR INLET. BELOW PIPES ABOVE COVER El v INI I (ELEV END I { FEET FROM NEAREST- MOUND SYSTEM: F ound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM d furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. I DYES ONO PERMANENT MARKERS OBSERVATION WELLS !SOIL COVER TExruRE OYES ENO EYES LINO SEEDED MULCHED. DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED CENrER EDGES. DYES LINO DYES LINO DYES LINO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE covER WIDTH LENGTH. NO. OF LTERAL SPACINMG'. GRAVEL DEPTH BELOW PIPE BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD . P IPE ANIFOLD MATERIAL. NO. DISTR. DISAT R. PIPE DISTRIBUTION PIPE MATERIAL & MARKIN ELEV. CIA.. ELEV.. PIPES D E ELEVATION AND ELEV DISTRIBUTION COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED HOLE SIZE HOLE SPACING DRILLED CORRECTLY I PLANS INFORMATION DYES LINO NUMBER OF PROPERTY WELL BUILDING. DYES tOB ' COMMENTS: PERMANENT MARKERS: RVA TION WELLS: FEET FROM LINE. ❑ YES ❑ NO ❑ YES 1:1 NO NEAREST Retain in county file for audit. Sketch System on SIG A U TITLE Reverse Side. U~ DILHR SBD 6710 (R. 01/82) 1 "71 U1 11^.II1 APPLICATION FOR SANITARY PERMIT ILHR COUNTY (PLB 67) cJi~G:~f~YV 'ro nr u e n nl M e lr UNIFORM SANITARY PERMIT # -J If ll lr l'.1ri,. l flf iol4r."innRr l "Et R I K 11.1!_; Attach complete flans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less thart 8'/zx 11 inches in size. --See reverse side for instructions for completing this application. PLEASE PRINT PROPtI;TY OWNr I MAILING ADDRESS - GLit7- OF ! v 0/i7/J /rL t/V J r J". r D PROPERTY LQWA1-ION .e}{ . 1,i;_ 1 /4 N, R E (or) V1, v1L p N LA E: _/V416,r0,V COT NUMRFf3 BLOCK NUMBER SURDIVISION NAME NEAREST ROAD, LAKE OR LA DMARK STATE P/L~AN I.D. NUMBER TYPE OF BUILDING OR USE SERVED i1 or 2 Fairlily Number of Bedrooms: Public (Specify): THIS PERMIT IS FOR A: New System Tank Replacement ❑ Repair Replacement Soil Absorption Systern L I Revision ❑ Privy Alter nate System Reconnection LJ Petition for Modification IIF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepayc lied I - I Seepage Trench Seepage Pit ❑ Holding Tank System In-Fill L_I In-Ground Pressure Vault Privy LJ Pit Privy Existing, For Which A Previous Permit Is On File, Permit issued An Existing System That Has Been Inspected And Is COMpliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed ,,wic Tank Cap,wity I , i Pump Tank (Siphon Chamber 1 Jlinul Tank cap icily r R'„oufactliie': ~✓~rStY~~. ~UMvt ~ _ IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: L.-1 Mound LJ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed ;-ww -Tank Capaf-uy I .11 Pump/Siphon Chamber - I'FRCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED {Square Feet): ~c19, X Private Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. N.une of Plumher (Print Signature: 1d4R/MPRSW No.: Phone Nurnber. .Too (/?/J-) ?orb Plurnhet's Address: G Name of Designer: _ °L_ 1~UL .('1 /t/ Gin.fy fr f -Qoi6 iv L(_ COUNTY/DEPARTMENT USE ONLY _ Signature of Issuing Agent: Y~ Fee: Date: ❑ Disapproved U Owner Given Initial Approved Adverse Determination IRee;rson for Disapproval Alternate course(s) of Action Available: J-~- "II IiIt SHU 634tt (R_ 5'82) DISTRIBUTION: Original to County: One Copy To; Bureau of Plumbing, Owner, Plumber /U3 67 85"02226 P Z OT A",O CAo.U J LG"i' 20n/ r~.ANS OVEr1 /00 IvOAT N lonu, PFr£TY Lr..,s AO IECT VILLAGE Or c~ To IT Grtvzx A10AT/4 NUOSOtV SIC to Ii 2 ST-615L -r~ fE,vc5 VZLLA 6F OF Non - ALT. Po,rr L,a? SZ" T E /8 y W,O.C UnJ ST_ C/2aax Co. /a.oo 6ALL..SEPM 30, t %'nuPoSEO /?ErT/tUOrh /3L1JG. n 6~~ F-/~tuPoJED 1A/EYL DV~R /ov' T~ rou1N ~iinPEn7y Ls►~E ~yy'` & A xT Ton of Lx~ST=n,~, //J✓2L120N S [o~vC/iF7G ~ C/?,OVEL Co,ZNER /'»ni1FD V,11 TN /AL t1^ Z1VZIM X25 TZrv G Lit Lr,1T L-71 C, _ /OU,oo h7 - /O~~t=,~ /~~2K sTS..G / AV ZLLSO/~ GRVOV8I Mt--S N AxA. -ZNLt?..r Amo 0,61F2v n T=o" PZPZ- ~ v 2 L TF f77_ e,, ~~1~ /~n 2 • ' S 13E T , G1LG ~P~tpN ~~T-- /aPP2ov~0 l ,ANT CAIN "1►, I~" AAoV SIGNED. DATE V D =s 'c ~ivxZM um or- !i y C1Q 7 1170AI o / r,AL 6AADE IN)UN »AY oa SYly-fVc-lG CcvErzrjv& d, 'Ai GGREGa7E ©Y/F_2 PIPE I or.rllmga7loo- n Pz.oF - o 0 0 o c o L r"vp7rd,~ 6~ED /II f ~n7T0!''ti I7F2 So.r~. v ~16~12r_`Gp?E ° Y&a~oaio~r~0 I APE ,l3~lo►.i TEST 2S 9S, 00 17 J3 rvFATrt PIPE ° CokPLSiu& TE'nrn:DvA7TNG A7 WA~aI ?faT ser,rrctr'ieac uD erAsRTME~'T OF NATURAL RESOURCES 1300 West Clairemont Avenue Call Box 4001 Carro,7p. Besadny Eau Claire, WI 54702-4001 Sscr~t~ry May 14, 1985 File Ref: 8700 Department of Industry, Labor, and Human Relations Division of Safety and Buildings P.O. Box 7969 Madison, WI 53707 Dear Sirs: The Village of North Hudson is proposing to construct a toilet/change room in Ferry Landing Park. The project is partially funded through the federal Land and Water Conservation Fund. I administer all LWCF projects for the Department of Natural Resources' West Central District. Village officials indicate that DILHR rules for sizing the drainfield at a park toilet use the park size as a guideline. The park is located on a 5.39-acre parcel of village owned land. The completed project will contain a picnic area, swimming beach, walking trails and scenic overlooks. The majority of the parcel is presently wooded and will remain so after completion. The amount of land to be cleared and use,i for actual recreation will be about one acre, with the remainder of the park remaining wooded. The guidelines indicate that a drainfield of about 4000 square feet would be needed for a 5-acre park. Based on use at the existing village beach, which will be abandoned, and estimates of picnicking and walking use, the village feels the park will receive an average of 75 users per day. Based on my experience with the area and my knowledge of the St. Croix River (I am also the Riverway Coordinator for the State of Wisconsin), I agree with the estimate of use. Because of the generally passive recreation use of the site, excepting the beach, and the desire to leave as much of the park as possible in a natural state, I feel it would be better to base the drainfield size on the one acre of useable space. In addition, because a new subdivision is being planned adjacent to the park, public sewer and water will be available at the park within 3 years. If you would like to discuss this matter with me, I can be reached at (715) 836-2941. Sincerely, ' 85-02226 Jake VanderVoort Community Services Specialist cc: Ed Boll -get John DeLaMater Duane Hof'stetter - SIDS/3 JVT450 TKDA TOLT2. KING, DUVALL. ANDERSON AND ASSOCIATES, INCORPORATED ENGINEERS ARCHITECTS PLANNERS 2500 AMERICAN NATIONAL BANK BUILDING SAINT PAUL, MINNESOTA 55101 612/202-4400 May 13, 1985 Honorable President and Board of Trustees North Hudson, Wisconsin Re: Ferry Landing Park Development North Hudson, Wisconsin Commission No. 7734-85 Dear Board Members: We have been made ware of the development plan for Ferry Landing Park within North Hudson. The trail system and passive park areas are being developed with an on-site septic system. This is an Interim system on approximately one acre of land which can be served with sanitary sewer and Village water within three (3) years. As an alternative to a drat of lel d which would require removal of trees, and affect the natural beauty of the area, we suggest a double tank system of septic tank and cesspool. This interim system could be relieved when san'i tary sewer Is extended within the plat of Sommers Landing to -the east or gravity sewer within Galahad Street to the south. The temporary system would require continuous maintenance and periodic ptaping based upon use. Routine observation would be recommended. Sincerely yours, -zJ John L. Davidson, P. E. Village Engineer JLD:j 85 - 0 2 2 26 Z i O o >F "mom p 0) i r~l > O C N O C p C cu z »7 E -6.2 E -6 C: \ U ay t p C F ~ A v p p N F- N QS ~ O ~ v c c i N V` 0p c 6 O j p E) N 0-0 -T CD 0) OM O 1-- Q N o~ tt- C V D y a) - N a) N C Ci 1 ca E o W °3~~0 $~t co N } Q w OL..L ~'a U) 70 0 r- U°3L lU W cu 0 a) cr) U) U) E.. Q ~LE "U)~ o a) r c U* 3 , ca - M c F- Q G 0) 3 ai cu Z 0 ~ . N c . V) N cv p Y c 0) vi O ; O 3°°~0° `°0rn cli w C) O U 5 a U p C7 VV O .0 v) Q U) :3 N CO Q d 0 a) C `rn- N a7 C c O c O r p a) i O fC i N .L (1) ` CO c 0 3 ca>,~ co C Z E = co p p O c c t ch CD 0) O= w a O ao a) a) O V ~O N E L p) C (D ~y N N i N a m U cu a) _ O p 7X 0) C a) 0 co 0 -0 cm 0 c: a H V O w Q) N d aa)i w 07 a of ° >+Y ° v~v>j E c ~~-C z cti cC cC O p O ui d L: O !A aD co CO U O) Y E a) 3 a) a) O ~ i N C S RY, T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOPe AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS ` J MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION SECTION: TpTpN~FTfp/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME E//Y~/ 1Y /T z9 N/R-10 E (o) N oRd os a ~EOxv . COUNTY: OWNER'SrI3'U ~b NAME: MAILING ADDRESN: sf.~to~X U,//~~ oF~, Nvos~~ U,r~rtI(, Nd f~upsco "s. s~o,~ USE - - L_Nevv DATES OBSERVATIONS ME EDF COMMER IAL DESC IPTIONPROFILE DESCRIPTIONS: PERCOLATI N TESTS: ❑Replace I 'L 1,?-g25 /~jt 75 E•~'Sa,JS sCs S~ Qn /l T! RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) DS 1:1U MS ❑U _D$ [:]U~E_]$ ZU DU LDUG ('oUf/f)f. aEo ri'x SZ~ f Percolation Tests are NOT required DESIGN RATE: GG~ SS If any portion the tested area is the under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: : ~..tf PROFILE DESCRIPTIONS IN ~C. F•)L . BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OB ERVED (SEE ABBRV. ON BACK.) > S ~i~ Cis S yJ, O 0 B Z s' s o~.Qa 7s/.S'BN. /s ~.S _ P._ t~P S .Q ~G- B 3 j ~0 • J-~f > s 3.3 ' 1~~ A,~ . s~ / G s G~~ s D r 5/ r /J~ _ ] 7 D R S (3N . S 2' IS ~3 ' Qom. s '3 B cP / ` o W• >gz. ~-4. S ~ 3.17'I-11'Y• RAP -!3a ca ~t . B- o c ~E T S eea.Q ~ B- J ~O S G . O(o 6, v PERCOLATION TESTS • TEST DEPTH WATER IN HOLE TESTTIME DROP IN VJA TER LFVEL 1JCHES RATF MINUTES NUMBER IN. AFTERSWELLING INTERVAL-MIN. pERI_oD 1 _P RIDO 2 PERIOD 3 PFR INCH P~ __~Q . - - > > - - P- ~ P /D > > a P- p_ ~v~P Zo.~T~- S~{ NO r ><T V E PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hor'- 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 3 O X ' PE/Q G -S i TES' SPEC / f'cK ct ~ /34 CA,AO~-- P~ ~s 85-02226 ,10 I Fz 4 3s• Y1' ' y f G ly AREA P3 (33 A~i Lyr ae r 1 c t 1 60 ~o . N ~ I _ ~y 31 t for a conventional septic systern. i rvE I ~i Nfr G ~~~~G s o~ -rop 'K tQ(Ui/N I ~Ul11100 'S Co u1G G~r_ Sc.q r C ~ I Ti* r J M A R f'--D ~~t_ fl G fJ ~ti vU y ~M fry"~ ~C J ~LEV f~~'1oJJ = c~ ~fi. ~ 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: PHONE NUMBER (optional): 2T' 3 oINEi L f } UDS o~ l~ ~S 5~~~ Sf~O2 Y~L 3 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER FTC /00 a,-v ld5 1 V # 41, APPL ATION FOR SANITARY PERMIT 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 h Location of Property~._it /9 rl~, Section T N - R ~ W Township Mailing Address y Subdivision Name Lot Number Previous Owner 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 resale (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) eenti, 6 y that att 6.ta tement6 on .thi,6 6onm ane .tAue to the but o4 my (ouA ) knowledge; that I (we) am (ane) the owneA (d) o4 the pnopelc ty de-6 eni.bed in .th id in6onmati,on 6o4m, by viAtue o6 a wa4Aa.nty e~V7!21 neeonded in the 066ice o6 the County Regizten o6 Deeds ad Document No. 3; and that I (we) pAuente.y own the p4opo6ed d•<,te bon the aewage poa ay6-tem (on 1 (we) have obtained an eadement, to nun with the above debehibed pnopenty, bon the const4ucti.on o6 said ey6.tem, and the tame had been duty neeonded in the 066iee o6 the County Regis teA o6 Deed6, a6 Document No. ) SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED