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Parcel 030-2032-40-000 03/30/2005 11:36 AM
PAGE 1 OF 1
Alt. Parcel 23.30.20.453D 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
MICHAEL J & JUDITH L CRAWFORD CRAWFORD, MICHAEL J & JUDITH L
147 HWY 35/64
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 147 HWY 35/64
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE
SEC 23 T30N R20W NW SE LOT B OF CSM Block/Condo Bldg:
4/944 BEING A DIVI- SION OF CSM 3/711
REPLAT OF LOT 1 OF CSM 4/944 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
23-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 710/452
2004 SUMMARY Bill Fair Market Value: Assessed with:
5983 221,800
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 91,200 127,000 218,200 NO
Totals for 2004:
General Property 3.000 91,200 127,000 218,200
Woodland 0.000 0 0
Totals for 2003:
General Property 3.000 53,500 104,500 158,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 143
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 61 r'tC t~1 TOWNSHIP 7 r U `:tE; ICJ SEC. T 2?s N-R W
ADDRESS P, 16~(A 54~K ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
o~0-~-~3Z-`fo ao~
PLAN VIEW
us ~
Distances and dimensions to meet requirements of I-LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
ell
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used (2, 19-
r ~
Elevation of vertical reference point: Proposed slope at site: lc)
SEPTIC TANK: Manufacturer: V" 6Q K 5 Liquid Capacity:
Number of rings used: ~ Tank manhole cover elevation:
Tank Inlet Elevation: b /j Tank Outlet Elevation:
Number of feet from nearest Road: Front ,Q Side, Rear, 1 ✓ feet
From nearest property line Front, 0Side, 0Rear, 0 / - ~ feet
1 r
Number of feet from: well building: &
(Include this information of the above plot plan)( 2 reference dimensiE SIDE septic tank)
SEE REVERS
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: P p/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufapturer: Alarm Switch Type:
Number o feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: -!51 Len$th: .570 Number of Lines: Area Built: ~~Cw
Fill depth to top of pipe: "
Number of feet from nearest property line: Front, O Side Rear, O Ft ~t
Number of feet from well:
Number of feet from building: t46'
(Include distances on plot plan).
SEEPAGE PIT
Size: umber of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
/eithea Hap box O or distribution box O been u
sed on any of the above soil
abs? (Check one).
HO Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from earest 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:
A rm Manufacturer: n
Inspector:
Dated: Z'- Plumber on Job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
L.APOR & H'JMAN RELATIONS SAFETY & BUILDINGS
P.OtiBOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Numbe.
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (1t a-pined)
NAME OF PERMIT HOLDER: ADDRESS Of PERMIT HOLDER:
7PPE 0 DATEMic hael J. Crawford R. R. 1, Box 254, St. Joseph, WI 54082
BENCH MARK IPe.mane..t reference point) DESCRIBE IF DIFFERENT FROM PLAN
R . Pt. ELEV. : CST REF PL ELE V.
NE SW, Section 23. T30N-R20W, Town of St. Joseph,Lot B, Don Rice Sub.
MP/MPRSW No.. Coumy. Sanitary Permit Number.
[P""T"
Gary L. Steel 3254 St. Croix 69658
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LALOCKING COVER
PROVIDED. PROVIDED IDED.
ES YES ❑NO
BEDDINGVENT DIA.VENT AILHIGH WA NUMPROPER TV W-. BUILDING. VENT TO FRESH
E ~ ` IAIRINLEr
FEET FROM / LI;
YES ❑NO ALARM ❑YES ❑NO NEAREST ~y
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER
WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED: PROVIDED:
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL L I ❑YES ❑NO ❑YES ❑NO
(DIFFERENCE BETWEEN NUMBER OF OPERTV wELL BUILDING I VENT TO FRESH
FEET FROM NE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
___j - SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LFNC;TH DIAMErEH MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until =FORCE
the soil is dry enough to continue.) CONVENTIONAL SYSTEM:
WIDTH LENGTNO. OF DISTR. PIP SPACING COVER
BED/TRENCH TRENC s NSIDE Dln SPITS DEPTH
DIMENSIONS V1 Al:
j PET DEPTH
GRAVEL DEPTH FILL D TH' DISTR P F DISTR. PIPE DIST RE
MATERIALNTR NUMBER OF
BELOW S PIPE SABOV OER ELENELE VEND- PROPERTY WELL. BUILDING. VENT TO FRESFI
LINE / AIR INLET
PI 7 FEET FROM
NEAREST
r Q Q r~C (G iJ (3.~. a~
MOUND SYSTEM: "
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVER TRENCH.BED DEPTH OVER TRENCH: BED ❑YES ❑NO ❑YES ❑NO
CENTER DEPTH OF TOPSOIL SODDED SEEDED EDGES ❑YES ❑NO YES ❑N:TM~RYEDES
❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF ELATERAL SPACING GRAVEL DEPTH BELOW PIPFILL DEPTH ABOVE COVER
TRENCHESDIMENSIONS
MANIFOLD PUMP MANIFOLD PE MANIFOLD MATE RIALNO DISTRDISTR. PIPE DISTRIBUTION PIPE MATERIAL MARKINGELEVATION AND eLEV ELEV DIA PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES -]NO
COMMENTS: PERMANENT M ARKERS: OBSERVATION WELLS. NUMBER OF I PLROPERTY WELL: BUILDING.
FEET FROM INE
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
sit A U TITLE.
DILHR SBD 6710 (R. 01/82)
vor
wlsconsln in APPLICATION FOR SANITARY PERMIT
I(~IDILHR r (PLB 67) (d&AX COUNTY
DE VF1RTmEnT OF UNIFORM SANITARY PERMIT #
- InOUSTRY, LRBOR 6 HumRn HELRTIOnS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY O NER MAILING ADDRESS
►~E ar t ttj°l j 15 X -3 5-'~ .S cEy /9 i . " s ~cg z.
PROPERTY LOCATION CITY.
1/4 LC.&4, S o7 3 , 1310„ N, R atJ v
~(Ot') W TOWN N OF::
O ~
LOT NUMBER BMBER SUBDIVISION NAME NEAREST OAD LAKE OR LANDMARK STATE PLAN I.D. NUMBER
A-,~ 4 wl 9 X71: = ) 5
TYPE OF BUILDING OR USE SERVED ~3~ -a~j3CJ ' ~v
X
jJ_ 1 or 2 Family Number of Bedrooms. ` ❑ Public (Specify):
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ 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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity Op 69
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: j
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
~ v,CJ CJ
z~c~Q ❑ Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installat' of the private sewage system shown on the attached plans.
Nar" Plumber (Print): Signatur. . IHff~FNIPRSW No.: r one Number:
Plumber's A ress: Name of Designer:
f)111 C .Yr/ &V
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent,:., Fee: Date:
/~/Ahl' El Disapproved
~ ~ i` SCI ~ f l '7 Ll Owner Given Initial
J / 7 Approved Adverse Determination
Reason for isapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To, Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
5 G
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SEPTIC TANK MAINTENANCE AGREEMENT p
St. Croix County z
r7
9
OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP
PROPERTY LOCATION: 14, 14, Section T _N, R W,
Town of 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 con-
sists 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 treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. o
E
z
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- '0
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
DATE
St. Croix County Zoning Office
P.O. Box 98-
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
TND
UTMENTOF REPORT ON SOIL BORINGS AND `SAF_ UILDINGS
TNL➢USTR`r', ~ IVISION
LABOR AND (115) ISON 1 5X 76
3707
HUMAN RELATIONS PERCOLATION TESTS
(H63.09(1) & Chapter 145.045)
i
LOCATION: SECTION: TOWNSHIP/N4A4HtttP-AtITY: LOTNO.:BLK. UBD N +
s T~o NRJ~A (or)W
'/a E'/a z / / ~ . P c~ ,~f~ a
COU. TY: OWNER' UYER' NAME: AILIN ADDRESS:
USE DAT OBSERV %TIO S1Vf
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
I)SIResidence 644L f, yvew ❑Replace g--12 RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:( optional)
VIS ❑U ~S ❑U SS DU D S ❑ S ,DU 1 41
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: &/f_J Floodplain, indicate Floodplain elevation:
~S%lY7Ql~ ~T PROFILE DESCRIPTIONS
BORING TOTAL ELEVATI DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER p 41N ON OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
17 - / Off' 3 i
3 1~'
B- IL EL o>3 c~ .'S;1. o,, , 0 -s 4-
s> > = ~ t
B 9= s`= 6A-)c ? ~
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 4l'ie"E7 AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ 3 A) b A: ,_'i 0 ~c t ' Z-
P_ d /U J C-)
P_ Pe (06C 2- Z !6~
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 ~2.? ~~c~✓
4.o' J~
EE- f a r
P'., I~VC)ArrS ~r 0, 10
yltl'
3
a 4
E
i
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):
rl~< l l J t 1 C=/" J~ . z z 9t 13~_ < / Z 00
CST SIGNLk9`~URIE,J
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DI LHR-SBD-6395 IR. 02/82) - OVER
mg, WUORM:
-T a ui _ s C { ira,, li 1, WKy , a,a rr Etter the a is a a sc'C c 1, t.ono erm al p ti4jmq
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vv ,t" .,.Yn { ymem;
a:tu !ue ,,REF ,a, by r i ; [axis. A ITL IS IU I r' BLS FOR A, HC),L.L?N{. [ '-?N , OP"ILY I F- 'ALL
W _R S a.a.,, w-f..sE HUa.._-40 a; t SED OtdrC,-L
PLEASE L 4' Ab . «°;a k O„ on ro Am i. l'. 'ki jfofil' d tp!io is ar°r
M„tF"E A LEGATE WOtt', ::fit at±1 ar mm1 des,,, in! Cif. _.an3-;, D „~„tta t F,. .t ,rt'efeiret~- A
,ilij,, et° > i Et ilEtf. le ,
,y a-„ t :,.`3 £91i,s_$?~. „a Slit ~'a`, s. ;:ac u. CA WY v~t 4, ,€~I, d are ~:it„y c3s't:i i%'
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County
d
a
y
OWNER/BUYER
ROUTE/BOX NUMBER Fire Number-
CITY/STATE l ZIP Z_
PROPERTY LOCATION: j 14, Section, T_70 N, R Z..G W,
c_
Town of tl Croix County,
Subdivision Lot number.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists 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 treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
I/WE, the undersigned, have read the above requirements and agree U)
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED f , e`
DATE 9 c-! j._
St. Croix County Zoning Office
P.O. Box 98-
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
APPLICATION 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/contractAr,("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 ~14 1,6y Section 2-3, T 3c~ N - R Z-G' W
Township Sevlr
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property ej~x
Total Size of Parcel . Q el Ce ot--r t
Date Parcel was Created =lyd
Are all corners and lot lines identifiable? e Y Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number 9 ~7 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,6y that a.Q.Q. s-ta,tementa on this 6onm she tAue to the bed.t o6 my (ouA)
Iinowtedge; that I (we) am ( oAe ) the owner (s) o6 the pnopen ty des cAibed in .th ,6
in6o4ma ion 6o4m, by viAtue o6 a wauanty deed neeonded in the O66iee o6 the
County Regis.ten o6 Deeds as Document No. y Z and that 1 (we)
pneaentty own the phoposed .6 to bon the sewage dizpoz bys.tem (on I (we) have
obtained an easement, to nun with the above descAibed pnopeAty, bon the
cons.tAucti.on o6 said system, and the same has been duty )Leeonded in the 066ice
o6 the County Reg.c,a-ten o6 Deeds, as Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
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