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Y Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERS TOWNSHIP A,~ SEC. T N-R
P:
ADDRESS ST. CROIX COUNTY, WISCONSIN
7F- z
' SUBDIVISION r C4- LOT 7 2- LOT SIZE
T
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N LU o{ 6p( iAa I,
C-
T ~ stall
r
.i
l ~~tStQ~.
66
T
31 a
-
133
`:a eQ 7 C
T
N
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used Z /
Elevation of vertical reference point: X/' Proposed slope at site: S~%S
SEPTIC TANK: Manufacturer, ~LJ 5a0 Liquid Capacity: 1Q0C7~rQ~~
Number of rLngs used: Tank manhole cover elevation:
Tank Inlet slevutloib: f0 'l'ank Outlet Lluvation: C/L.
Number of f ,!et from nearest Road: Front, Side, Rear, O feet
From tearest property line Front,OSide,®Rear,O feet
Number of feet from: well building: j4 (c>~,,,- L4 ~ j 9(crvr,SJc~tSlt2ti
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
e
PUMP CHAMBER
Manufacturer: ZLiquid 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, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: ft In Trench:
Width: I Length: 3 Number of Lines: 3 Area Built : b t/ `C
Fill depth to top of pipe: 2
Number of feet from nearest property line: Front, O Side, Rear,O Ft.~ ? C /
Number of feet from well: 2 1
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:
InspectorI~
Dated: ! Plumber on job::
License Number: C~
3/84:mj
i
DEPARTMENT OF INDUSTRY, INSPECTION RcEPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 5:, 07 BUREAU OF PLUMBING
XkONVENTIONAL ❑ALTERNATIVE SlaiePlan ID N,mber
Holding Tank L] In-Ground Pressure ❑ Mound (If assigned)
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION D TE
Sam MiUetc Thoutbtcook Rd, Box 282, Hu6on, W1
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV.: CST REF. PT. ELEV.
NE SE, Sec. 7, T29N-R 19W, Lot# 22, Eagte Ridge, Town o6 Hu6 on
Name of Plumber. N
MP/MPRSW N. County Sanitary Perm, it Numher.
Dougt" S;r.ohbeen 5432 St. Ctl.oix 54910
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
• LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
~I PROVIDED: PROVI DED.
❑YES LINO ❑YES LINO
BEDDING: VENT DIA.. VENT MATL 11HIGH WATER
NUMBER OF ROAD: PROPERTY WELL BUILDING JVENTTOFRESH
ALARM. FEET FROM LINE~~ AIR INLET
YES LINO ❑YES LINO INEAREST v 6 ~5 ,
DOSING CHAMBER:
MANUFACTURER BEDDING.
LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTI RER` WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES LINO [:]YES LINO ❑YES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPFRTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE AIR INLET'
PUMP ON AND OFF) ❑YES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FNaTIi DIAMETER 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
BED/TRENCH ( - rRENCiFS I NSIDE DIA -PITS LIQUID
DIMENSIONS I "'~S aIAL' PIT DEPTH.
GRAVEL DEPTH FILL DEPTH DISTR. PIPE Y DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTH NUMBER OF PROPERTY WELL. BUILDING'. VENT TO FRESH
ABU COVER ELEV. INLET ELEV. END 1 PIPES, LI
BF LOW PIPES NE. AIR HOLET:
(I -.T f FEET FROM 1
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
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.
LI
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES LINO ❑YES NO
DEPTH OVER TRENCH 'Btu DEPTH OVER TRENCHBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR. IDISTR. PIPE DIS TRIBU'lON PIPE -MATERIAL & PAARKING
ELEV.. ELEV. DIA ELEV. PIPES DIA..
ELEVATION AND
DISTRIBUi ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES NO ❑YES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF uPROPEE
RTY WELL. BUILDING.
FEET FROM N
❑YES ❑ NO ❑ YES 1:1 NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
FGSJI Ng1rV E TITLEDILHR SBD 6710 (R. 01/82)
MMMM4 Wisconsin APPLICATION FOR 'SANITARY PERMIT "
' DILHR COUNTY
- oEPRiiTmEnTOF (PLB 67) UNIFORM SANITARY PERMIT #
InOUST.^V, LABOR& MUMRn RELRTIOnS
-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 OWNER MAILING ADDRESS ~i
~AMZ~ 47; I ff-r' 7t4'r Rlo rJ ppy
PROPERTY LOCATION +
E 1/4 1/4, S '7 , T Z? N, R 4 (Dr W I-~~d5~ ~1 dvr j-yv/~
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST /R~OAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
2-2- A14 grj /a- k1--Z TYPE OF BUILDING OR USE SERVED
y 1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
X 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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity ~OLjG3
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: GO; -Z-'s
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
/
Sept 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):
91, & 1!!5- (11 IV? 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): Signa ure:
MP/MPRSW No.: Phone Number:
IMP-S"13--l (ZIT-32-33)
Pluu bber's ddress: Name of Designer:
1l F L(.~ A *;e,11 K✓' N ~i
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
f A,) ~k,,Lw ' 1 d~ {x ❑ Owner Given Initial
( CT - ~.J 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); 4~
2. Indicate specifically what type of use is served, if public hecked~*dicate 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.
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 !51+M Wli (It-I'
Location of Property E- __~4 5E ~4, Section T N - R Z!?-
Township I~~ t/S T
Mailing Address T%l2tatD
Subdivision Name je,
Lot Number 2 Z.
Previous Owner of Property Z, 5 ;!std
Total Size of Parcel a .Q 7 AG~a 5 _
Date Parcel was Created s,..
Are all corners and lot lines identifiable? X_ Yes No
Is this property being developed for resale (spec house) ?Yes No
Volume S~ and Page Number ,30 3 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 witl, 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) e 6y that aU statements on -tha 6oAm aAe ttAue to the be/sl-- o6 my (ouA)
knowledge; hat I (we) am (oAe) the owneA(a) o6 the ptc.opotty deScAibed in ttaz
in~o,,mati..on 6oAm, by viAtue o6 a wahAanty deed AeeoAded in the O'4,ice og the
County Rego teA o4 Deeds as Document No. > ; . ;-z; and that I (we)
pnesentty oun the p4opo,6ed site 6oii the sewage di,6po/system (oA I (we) have
obtained an easement, to nun with the above d"cAibed pAopenty, 6oA the
eons Auetioy o6 said system, and the same ha/s been duty Aeco&ded in the 066ice
o4 the CounA y Regi.5teA o6 Deeds, as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
• H
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S `C C - 105 r
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SEPTIC `LANK MAINTENANCE AGREEMENT
0
SL. Croix County 1
C7
Y
0WN1;R/NUYEI:
ROUTE/BOX NUMBERIEF40 Fire Number
C IT Y/ STATE
PROPERTY LOCATIUN:* '4, _5F- Q, Section 7- 1 2~ N, R
Town ofhAcz_!'7_ St. Croix County,
Subdivisi_oua1~~ Lot number
I
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 sehtic 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 maw be eligible Lo receive a grant for
a maximum Of 60% of the cost_ of replacement of a failing system,
whieh was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement Lhat
owners of alL new systems agree to keep their systems properly
maintained..
The property owner- agree: to submit to St. Croix County Zoning a
certificatiun form, signed by the owner and by a master plumber,
journeyman plumber, restrieted plumber or a licensed pumper veri-
fying; that (1) the on-site wastewater disposal system is in proper
operating condition and (2) atLet lpsoecrLon 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
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ~u
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning O fi.ge within 30 days
of the three year expiration date.
SIGNED
~noyyjqg
1) ATL
St. Ctuix County Zoning Office
P.O. lox 98
Hammond, W1 54015
715-756-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF
INDUSTRY REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
; DIVISION
LABOR AND PERCOLATION TESTS (115) MAC JSON, WBOX 76
HUMAN R REELATIONS
I 53707
• (H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNS IP/ I Pd 81 FA I= +Y: LOT NO . K. NO.: SUBDIVISION NAME:
/VE'/a
CO
UNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: / t
Sit pe
USE DATES OB ftVATI0 S MADE'
NO.BEDRMS•: COMMERCIAL ESCRIPTION: PROFIL DE 1PTIQjJS PERCOLATION TESTS:
esidence ® ;~gVew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system S
rCONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-I -F L HOLDING TANK: RECOMMENDED SYSTEM: (optional)
If Percolation Tests are NOT required DESIGN RATE: [Ff an
y portion s the tested area is in the
under s.H63.09(5)(b), indicate: loodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
z
BORING TOTAL/ DEPTH TO GROUNDWATER-1*64-I CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH•+h!< ELEVATION OBSERVED EST. HIGHEST TOO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B r r ! ~Q• •\i .Gas- ~II 6 Bn ~1~ aZ A4 ~f`e
r -y'
B-
i'r S
B-3 o, $ A s ~ a2~,.Z ,E~'r+~ •`/C~ O J
C 61 2-2- BCE , 40 -s / 3 S'~t
a ~4 161 4Y10n /j 31s 6.4 51 3-.,5-- .4,1
B-
PERCOLATION TESTS
TEST DEPTH i WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER R+6" AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- J Q / 3
P-
3' o L
P_
P-
Pp
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 ~st-~ le 6~ea, J_
r S / 4 tle~- 71,
Vic'
NY _ Fs_~.~Q~skw,k
ly,
0 pi (~j____•- Lai- Cv~-:k - A t- I I" -tl Sh .cs
13 ' 0 AA Est .cwt ~ N
04
0900
"of 70 ~'e to
Steal i t ~'cr 7~C` ~e to
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:
J
HONE NUMBER (optional):
1
CST S ATURE:
y,
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
OWNER/BUYER
e~
ROUTE/BOX NUMBER k 2 -At'? Fire Number
CITY/STATE a ,,L%nioe` u_') `LIP ` 0(
PROPERTY LOCATION:4~E .4, ,5_f-- 4, Section , T 2-1-N, R/ 'I _W,
Town of'waJ6g2 :z St. Croix County,
Subdivision q cam, 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 stems 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.
0
E
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
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
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.
APPLICATION FOR SANITARY PERMIT
STC - 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 -2 J-~--~=
Location of Property, Section T N - R W
Township
Mailing Address N' r~ - -:2- Z,,-
- 1
Subdivision Name
Lot Number `
Previous Owner of Property
Total Size of Parcel -217
1J
Date Parcel was Created
I
Are all corners and lot lines identifiable?_ Yes No
Is this property being developed for resale (spec house) ? Yes X No
Volume ` and Page Number 116- IT 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.
PROPERTV OWNER CERTIFICATION
I (We) eexti.6y that att statements on this 6o4m are t4ue to the but o6 my (ouA)
knowledge; that 1 (we) am (are) the owner (s) o6 the propex ty des n i.bed in this
in6onmati,on 6o4m, by viAtu.e o6 a warranty deed recorded in the 066ice o6 the
County RegiAteA o6 Deeds as Document No. 39 ; and that I (we)
presently own the proposed site bon the sewage dt6posat system (or I (we) have
obtained an easement, to run with the above des eh i.bed propeA ty, 6or the
const.u.cti,on o6 said system, and the same had been duly neeonded in the 066ice
o6 the County Reg.i6teA o6 Deeds, as Document No, y S -S YF )
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED