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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER l'rcRw~ / TOWNSHIP SJu~E?:SSC SEC. T N-R_ _W
ADDRESS BD;< 5i3 ST. CROIX COUNTY, WISCONSIN
S/, 'T aC?~~/
SUBDIVISION ✓^f 149,
/gyp LOT LOT SIZE PLAN VIEW
Distances and dimensions to meet requirements of ILH.R 83 1
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
j~, A
/ r
c
(i7 t _ - -
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used Z m ,Ql
Elevation of vertical reference point: Proposed slope at site: 2 /p
SEPTIC TANK: Manufacturer: 5_7J~/qOJ jq' ~B,iquid Capacity: xy)6 a rd
Number of rings used: 6. C Tank manhole cover elevation:
Tank Inlet Elevation: Cn~ -'S Al Tank Outlet Elevation:
Number of feet from nearest Road: Front, ~Sideo Rear, 0 feet
r
From nearest property line Front, Side,n Rear, O feet
Number of feet from: well building: 5 r
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: 1j Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation-of inlet: r
~~Q Bottom of tank elevation:
Pump off witch elevation: allons pgf c cle:
Alarm Manufacturer: larm Switch Type: r='
i
Number of feet from nearesjt prop rty lin /Front, ide, O Rear, Ft.
h
Number of fee from we 1.:
N mber of feet from building:
(Inc Vu distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
i
Width: Length: Number of Lines: Area Built: 9~jo
Fill depth to top of pipe: 'X00 /
Number of feet from nearest property line: FrontT O Side, Rear,O Ft.,(~Q
Number of feet from well: _51-6 Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT NI)k
Size: i A~umbe of pits• r-. Diameter
Liquid de~th: Bo om of seep Lgj~Zelevat n:
Area Buil :
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytem`sr? (Check one).
HOLDING TANK
Manufac er: / Capacity:
Number of ri gs used: Ar Elev tion,of bottom f tank:
T
Eleva 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:
Inspector. J lit; wccCS ~l~ V `mod f~'~
Dated: Plumber on job:
c
License Number: A
3/84:mj
Parcel 032-20255-60-000 01/31/2005 12:23 PM
PAGE 1 OF 1
Alt. Parcel 7.30.19.566E 032 - TOWN OF SOMERSET
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
* DOT, STATE OF WISCONSIN
STATE OF WISCONSIN DOT
718 W CLAIREMONT AVE
EAU CLAIRE WI 54701-5108
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 384 169TH AVE
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE
SEC 7 T30N R19W 5.OOA IN NE NE LOT 2 CSM Block/Condo Bldg:
VOL 1/190
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-30N-19W NE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
02/04/1999 597117 1401/203 WD
07/23/1997 717/495
07/23/1997 693/507
2004 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: "~ast Changed: 06/22/2000
Description Class Acres Land It Total State Reason
STATE X2 5.000 0 0 NO
Totals for 2004:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2003:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch 210
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
I I
I
Parcel 032-2025-50-000 01/31/2005 12:24 PM
PAGE 1 OF 1
Alt. Parcel M 7.30.19.566D 032 - TOWN OF SOMERSET
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
" DOT, STATE OF WISCONSIN
STATE OF WISCONSIN DOT
718 W CLAIREMONT AVE
EAU CLAIRE WI 54701-5108
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.010 Plat: N/A-NOT AVAILABLE
SEC 7 T30N R19W 5.01A NE NE LOT 1 CSM Block/Condo Bldg:
VOL 1/190 EXC TO STATE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-30N-19W NE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
08/27/1999 609412 1452/329 WD
07/23/1997 850/166
07/23/1997 726/554
2004 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 03/20/2000
Description Class Acres Land Improve Total State Reason
STATE X2 5.010 0 0 0 NO
Totals for 2004:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2003:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
i
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT AF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
P.O. BOX & HUMAN RELATIONS
P PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BO
MADISO f1I, WI 53707 BUREAU OF PLUMBING
• MRCONVENTIONAL ❑ALTE R NATI VE State Plan ID Number
El Holding Tank 1:1 In-Ground Pressure ❑ Mound (1f assigned)
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
William Kill RRBox 553, St. Joseph, WI 54082 ~0-f~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. IT ELEV.
NE NE, Section 7, T30N-R19W, Lot#2, Town of Somerset
/No
Narne of Plumber. 7_7
County Sanitary Permit NumberJohn P. Sykora, III 2 St. Croix 64925
SEPTIC TANK/HOLDING TANK:
MANUFACTURER L
LIQUID CAPACITY. TANK IN ET ELEV.. TANK OUTLET ELEV WARNING LABEL
LOCKING
PROVIDED'. PROVIDED OVER
,e
®YES ENO EYES [ONO
BEDDING: IVINTDIT VENT MAT L.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING'. VENT TO FRESH
i { ALARM LINE: AIR INLET.
FEET FROM
EYES NO EYES NO NEAREST
DOSING CHAMBER:
MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED'.
❑YES ENO EYES ENO ❑YES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS ERATI, NAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN ! FEET FROM LINE I AIR INLET
PUMP ON AND OFF) ❑YES '/ENO NEAREST 110
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing It FN(,TII JDIAMITEH 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.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO . OF DISTR PIPE SPACING COVER ]:~:TSI
DE DIA #PITS LIQUID
BED/TRENCH f NO HES
DIMENSIONS ~ NAVERIAL DEPTH
GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO. DI TR NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. INLFT ELEV. END PIPES LINE'. AIR INLET
FEET FROM
6 4 2 NEARESTs
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-
EYES ENO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ENO ❑YES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
EYES ENO ❑YES ENO ❑YES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS M
MANIFOLD PUMP ANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAHK i7G
ELEVATION AND ELEV.. ELEV.. CIA ELEV.' PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ENO ❑YES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROP ERTV WELL'. BUILDING:
FEET FROM LINE:
❑YES ENO ❑YES ENO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE'. FLE.
DILHR SBD6710 (R. 01/82) 4.,<
wlSCnSIn APPLICATION FOR SANITARY PERMIT ,
D* ILHR L COUNTY
(PLB 67)
i
V OEPgRTTEnT OF UNIFORM SANITARY PERMIT #
V- In DUSTRV, LABOR 6 HUmgn RELFITIOnS 6 ll K
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP
WOA'4al Will --rl-T &,X 5-63 Ll ERTY OWNER MAILING ADDRESS
PROPERTY LOCATION CITY:
_VII I AG:
AIE114 Vi/4,s7 , Y-4), N, RFC E (o) W T
OWN E _S6
LOT NUMBER BLOCK NUMBER SUBDIVISION~ ~M ST ROAD, AKE OR LANDMARK STATE PLAN I.D. NUMBER
tit -p66 fi 190 ~ 18 S. `E 16 5 ' s 7`
TYPE OF BUILDING OR USE SERVED 03a~ Q
1 or 2 Family Number of Bedrooms. Public (Specify):
THIS PERMIT IS FOR A:
1ANNew 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.
>X 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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity 0® 0/6
yl~ V,
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: _S7 d 1 ~ -
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):
9 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Si tP/MPRSW N Phone Number:
! A (,t, ~ -c 'mac' i (7 S) .SG
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signat r of Issuing Agent: Fee: Date: ❑ Disapproved
- 3'7.~~ 1,~~~J ❑ Owner Given Initial
v Approved Adverse Determination
Reason for Disapproval:
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.
.?Y N
WENT , rF REPORT ON SOIL BORINGS AND SAFETY&BUILDIN
;y, DIVISION
-30R AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069
HI;n A" ~
Al rATIONS
(H63.0911) & Chapter 145.045)
LOCATION: SECTION: A_T?OWN;1HIP/W7- A4N+G+P 'TY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
N E /4 /T30 N/R If E L SM oo~S Uo% / n /
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: ~'s• S
5Y • C~,o ix A .m • /l/ H-1 A o X S5 3 s4 . Yod'
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: P OFKLE DESCRIPTIONS: PERCOLATION TESTS:
e ~ N A4- ew ❑Replace , 0 -
(RATING: S= Site suitable for system U= Site unsuitable for system SCS f}MERy ~o~i'1 / J
CONVENTIONAL: MOUND: IfV-GROUND PRESSURE: ISYSTEM-1 N-F1 LLIHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑ U W] S ❑ U S ❑ U ❑ S [j] U ❑ S U CON USN Ti6.vhL / ae T,PE,t! ~kr
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: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS At DQCiMAI- Fr
BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH . ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEEnABBRV. ON BACK.)
r i 267' N-Gy GAM, • /Gv-1OAM, /J_5' 14jzi'%R S J
B O s" 2S ' hi/• of /ooA (14). S1 ly-4
00.O f > 7f',6A3-&y. /oAh 47S' (ia. /DAM, 6•S'kiK, af- hoje
B O y 7.0 C,
o . S/' roe. S. W
. v % Y 56 qtr > 'F. d " Z l7' 4,0 - &y. 10A M !.S'3 3430. /oA,,i , 5 • vliy 5
B-3 i.0'
HJY• oS 9W• S( Ra . S
nOi , O 0 •7S'aN-(yy. /0A14 .(06 (,J• OA 14,
S day ) ~'o~'
B- / t0 ~'L(j.• Q is f F+'Oc- . ' S f
B!~' j75(~ At, BAj.-6- y, /0 A.11 ,fi.' 4e-3 -3 . f'W 57 , 75'x' J4iY.~
,V . •-S.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- . Z
P- _
P- Z 66 ,30 /
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. 12 atf~~ O
SYSTEM ELEVATION
VAIQ~" fat L/;vi5
IF M
yo This test Sh APPROVED
hobo u
~oQ E yaT. pl/ e, ser for a conventional septic system. _ ~
~I . ;Soil rtST~ . u
A~
to OP
(1cle 10+
P JD
/0 0 - p ' 19
Q
$ fSTE~ f , ro G%t: //AJ
'A P1,
3 31
3), x . 3 E
t
13 ys
< 3o rl' ,
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
Administratiyg•-Cp0e, and that the data recorded and the location of the tests are correct to the best of.my knowledge and belief.
NAME (print): RON TSM 1 ESIN17 to. TESTS WERE C ETE i ON~
S PROVED CIlJ1Yl SITE 1 1 EVALUATIONS \J ( TC (G /L,G
If f DRESS: CER FICATION NUMBER: PHONE NUMBER (optional):
MINNESOTA LICENSE NO. 00663
WISCONSIN I.IC'ENSE N'0 5542410 STS L y~ L -
RT.30O NEIL RD., HUDSON, W1 W16 CST SIGNATURE: .
•N I
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
' r~
av my c3"x.i „t., o ! = Yew 0000 rm"t €9 E€:py:
tai crlptlon"
uw! eec iitt.. in List A o l nidivit e whi;!: w, 10t; a r3 `~'4kt. C„ I t7 u3 afT1G'i`Cire 'fzaf
L%<,< X„~vil. Itf .er,n:;asr iyi E€i-,€.;ras "{"#5 „ "'otY7t ,C,ki io€ use o-.''.is'iill'd;
OTHER SYMMS ARF !Mi&D C)LIT HAM! ON SOIL CONDITIONS;
PL EASE we We ¢:t.:,t S.'€:S. ni .l(:i, i" stdF PiW,. (4 hpi-i..,n's and ccitnoiL,~:. 1gidle1:,f i-)lark
,uA E . , LEGIBLE "1AW , am mly , wu_ ; a , " Mc x otes, w woe . pwvf , d A
, 'Y ,C7, 'f.`§`' .E.,l€€;a Y A v ai Roil a whor , i. i i nice t. uof a X df.a dJ shown, wid ai tJ €"r5..3nnic;
u wwle a € i3p(-7i; t „a e o x es as in W; [aww" ,.(,,f`yw ,fry .,,i plain dal.a, pelcoi'ltio l tesE extoylp-
M.t if do
1; nn QN, as Now! Awn. , f. fa `i;ik`x, ;Arm F LA. K he am p d.€i:a box;
E _ lotin "mid
,r ri o v n,; W, R M &C
Cottle p 101 SS smovimmw
Ssl `st= ["?UN._ i-`€ttC Fi.F€ °}t iV't?tiif-
coarsy Saw!
`3 .'ice a
FPv W
Loony a_,_r , P lAv ,.d Thai
- <iEi
's Los R r,
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;7 too! Mun
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Pew wnn et{Ft .l Et ,.j
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wain 10'e;'
Z Wj AK WTI
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. ~ ..Y,i i s: 5 pi , ii- bI rt e rid a,%`. < ,:;;i. , o I~t,o? i h £ cc ,u >it. c„ TiFi3 DeV73i"$f't`] ftt T; lt3 y 3 i..jtlr3`>i: ,
r=i..,. nx"nu, . iE-aA t ,3tr1[° a), ar.i, i:Io.n,.
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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/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 _ \ e~ v t• y\:A_ v,_ ~1~ ,
eT
Location of Property -~4__~G Section T ]1(J N - R \r' W
Township )
Mailing Address S,A
~sQ:~r~~ .tea U
Subdivision Name
Lot Number
Previous Owner of Property F1S1 S.~ FrOns~s.ti - EwJic-n
;~C_
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? X, Yes No
Is this property being developed for resale (spec house) ? Yes_ No
Volume 53'7 and Page Number i~ r7as 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.
PROPERTV OWNER CERTIFICATION
I (We) eeAti.6y that att .6ta.temente on th.ib 6o4m ane .true to the but o6 my (owe)
know.P_e.dge; that I (we) am (cute) the owneh(e) o6 the pnope&ty duc4i,bed in .th,i.d
in6a4mati,on 6o4m, by vi tue o6 a wann.anty deed teco4ded in the 066ice o6 the
i County RegiA ten o A Deeds ae Document No. 33;29 9 • ; and that I (we)
pnedentf-y own the pnopoeed A to bon the sewage poea byb.tem (oh 1 (we) have
obtained an eademen.t, to nun with the above dedeni.bed pnopeAty, bon the
conet.ucti.on o6 said &y.6te.m, and the &ame hab been duty neconded in the 066ice
o6 the County Regia.ten o6 Deeds, ab Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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