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HomeMy WebLinkAbout020-1158-60-000 C-) cn O 3 m n d G m f c W o cc ~ 1 > > 0 3 3 fD 0 (-0 I v ~ m ~ ~ n O M N 0 O CO C W O 0 3 o~ ro -N o Q N o • n Z a N co ? O CO W NN 8~ n 0 CD 0 Z3 (D 0 'CO o 'A' N O co 0 O 7 N O C C (D v (n D m a m CD G CD (n N W (D C: C w 3 0 Ow ° a N p °o CD C,) N c ~l co CD 0 co 0 N o r- cn G' G N co c N Z O O O .d. r-1 A A O C-0 CD O t[~~~l O O n Q C (n to co W CD 0 CD Z rn a o R '0 N - m 0 1 + (C H D 7v CD cnn n > f 3 D ' Z ° ~I t ro O D Q :3 tz1 N N • d s o (D 1' (n L7 m (c N I 00 W W N O ~ O a 3 co 0 Z (D CL A Lz) TJ Z w L Q TJ ° co v r)i w (o CD W co 3 C) :At ;s y z la, D N f ~ w 41 C~ ro D O r, O G cc O SU -n O C N OZ a 77 CD N N N O ~ N (0 A x a ro O 0- ;z- CL ;s CD O III V ti O O a A O R7 t-j A ~O O ti a ya O O O a- ~ Parcel 020-1158-60-000 06i07i2006 08:11 PAGE 1 OF 1 F 1 Alt. Parcel 23.29.19.893 020 - TOWN OF 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 - OLSON, MELVIN K & DEBORAH J MELVIN K & DEBORAH J OLSON 819 KELLY RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 819 KELLY RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 4.060 Plat: 1903-DEL'S WESTVIEW ADDITION SEC 23 T29N R19W DELS WESTVIEW ADD LOT 6 Block/Condo Bldg: LOT 06 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 687/431 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.060 93,200 229,200 322,400 NO Totals for 2006: General Property 4.060 93,200 229,200 322,400 Woodland 0.000 0 0 Totals for 2005: General Property 4.060 93,200 229,200 322,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 134 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form- S T C - 104 A AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP U~ SEC. T Zy N-R~W ADDRESS /a ST. CROIX COUNTY, WISCONSIN 01 7. SUBDIVISION ~ESrU/EtJ LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM W ~ c y G ~E v~ ~ /o, So W Erl oc K~ 1,0 r s A R~ 3(v 2,41 INDICATE NORTH ARROW BENCHMA . Describe the vertical reference point used Tire im Elevation of vertical reference point: /<5Z , Proposed slope at site: SEPTIC TANk.: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: ( 71 ' Tank Inlet Elevation: p S Q / Tank Outlet Elevation: O J~ Number of feet from nearest Road: Front,© Side ,\,W Rear, O > feet feet From nearest property line Front, OSide, 0 Rear,O Number of feet from: well 5 0 / building: 1/3 r (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVFNSF S I hl` 44 PUMP CHAMBER Manufacturer: Liquid Capacit Pump Model: Pump 'phon Manu turer: Pump Size Elevation cf l„lct: Rn m of tank Pl--•_-ion: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of fee rom nearest property line: Front, 0 Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM R Bed: X Trench: Width: Z y Length: J ~o Number of Lines: Area Built: Fill depth to top of pipe: A Number of feet from nearest property line: Front, Side, O Rear, O Ft /S^ Number of feet from well: 7 / _,-0 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: om off 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 in 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: Inspector: HUMESITE SEPTIC PLUMBING CO. ROBERT ULBRICHT Dated: Plumber on jobWIS MASTER P! MIN-N-5,18-TALLER & DESIGNER LIC. NO. 00W4 License Number: 3/84:mj DEPARTMENT OF-INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & 'HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION ` P.O. 60X•7969 BUREAU OF PLUMBING MADISIJN,,VI 53707 ' ® CONVENTIONAL ❑ ALTERNATIVE State Plan l).D Number (lt assigned D Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER'. INSPECTION DAT Metvin Otson R. R. 2, Huctson, W1 54016 el30 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST REF. PT ELEV.. SLY SW, Section 23, T29N-R19W. Lot#6,'DeV s We~stview Add., Town ob Hud6o Name of Plumber. IMP/MPRSW No.. County Sanitary Per- N-ber_ RobeAt U.LbAicht 3301 St. Ckoix 49488 SEPTIC TANK/HOLDING TANK: MANUFACTURER'. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER ~i 11 r-. i PROVIDED. PROW ED- f YES LINO P YE" ENO BEDDING: VENT DIA.. VENT MAIL. JHIGH WATER NUMBER OF ROAD: PR OPERTV WELL: BUILDING ENT TO FRESH _ ALARM FEET FROM LINE: AIR INLET. DYES NO DYES ENO NEAREST DOSING C AMBER: MANUFACTURER JBEDDING. LIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES ENO EYES ENO DYES ENO GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY [11 LL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 17FIMATIRIAL 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 JNDISTR. PIPE SPACING; COVER INSI OF CIA -PITS ILIOUID BED/TRENCH , TRENCHES M,7ERIAt\. PIT DEPTH DIMENSIONS 1 4 GRAVEL UFP1 H FILL DEPTH J I DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO DISTR NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV. INLE f ELEV. END/ PIPE LINE AIR INLET. G. L FEET FROM / s f / . ~ ~ NEAREST--► 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- D meets the criteria for medium sand. TIONS MEASURED. YES NO i SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ENO DYES ENO ~ DEPTH OVER TRENCH BED DEPTH OVER TRENCH-FEE) 7 F TOPSOIL SODDED EDED MULCHED CENTER EDGES / 14J DYESA ENO DYES ENO DYES ENO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TR EONCH ES LATERAL SPACING JGRAVEL D PTH E OW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD M T RIAL. NO ISTR. ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV. DIA.. ELEV.. PIP S'. IA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY OVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES NO DYES ENO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE S ❑ YES ❑ NO ❑ YES ❑ NO NEAREST cj. Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE - r{'✓ TITLE'. DILHR SBD 6710 (R. 01/82) ' / wl sconsln EnT APPLICATION FOR SANITARY PERMIT ®1 L H R COUNTY (PLB 67) E7E UNIFORM SANITARY PERMIT # InOUSTRV,LgBOR 6HUmgn REIRTIOns Al off -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 PROPE Y OWNER MAILING ADDRESS /M) V/,j D~to-~1 P17-. 2-- uDro-J , 41 / s- .f 5`61 CP PROPERTY LOCATION C177" v s 1/4 1/4, S , T4, N, R E (or) /O J(Y TOWN OF: LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, TTATE PLAN I.D. NUMBER Co KEG'S GvFSiUiE~ fI~D%T . TYPE OF BUILDING OR USE SERVED 0CV0 . S -0co K 1 or 2 Family Number of Bedrooms. Public (Specify): THIS PERMIT IS FOR A: 1~ 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 Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: VZ_Z~ Co 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): PROPOS /l(Square Feet): 9 O Z7 rX ~~g I)] Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Prin Signature: n~n~ VP7MPRSW No.: Phone Number: OMESITE SEPTIC PLUMBING CO c%LX 1 3 3,o 15 ' RT. 3 O'NEIL R Plumber's Address: ROBERT ULBRICHT Name of Designer: WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved / ` ')c f L~ Owner Given Initial (f/ Cts 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. 7 PLB ~ PLOT Qn8 CR o w s ri o N FIANS N yo r'C (~a r ffn~r~sjr~ ; 36,b06 ' PGr0jr . s y sr_-M fo ~vt l I /3' I Z /~O USF { O I 2o' PR; 0E- W Ay i ~ f i~D G r~ 1313 P1, Gjtf'%'~` rAt E~ ~J. C?/Sow Cr~* 01 2- br s~ _ `6 S'sNED .~1 i_0 T- LoT Fresh Air Inlets And Observation Pipe -Approved Vent Cap t+OM~S\c `v" ~Uv bR\CN~30N0 00 ~3 C _ WS~,J Minimum 12" Above ~~,~tiSFrv Final Grade 4" Cast Iron Above Pipe Vent Pipe r f'~'oT-7 . -ro Final Grade Gi r Marsh Hay Or Synthetic Covering Min. 2" Aggrle Over Pipe ~f Distribution Tee Pipe 0 0 0 3. Pi Aggre gaPerforated Pipe Below Beneath PiCoupling Terminating At 'Bottom Of Sy stern Y INDUS TR OF' DEPAR REPORT ON SOIL BORINGS AND.r frET~¢~t'ILDINGS NDUSTRYY, , ee~~1 LABOR AND ,t~: / v '~T,!`, VISION PERCOLATION TESTS (115)`_ X 7969 HUMAN fi~LATIONS ~IA`b Nr. 53707 3.09(1) & Chapter 145.045) LOCATION: SECTION: P WNSHI M NyCIPALITY: LOT O.:BLK. N BDIV e_ N NAME: /„9• SGT ~/~/a /Td ~ N/Rj E ( ) W c~c! fi_`,_ COUNTY: OWNER'S/BUYER'S NAME: MAILING DDRESS: r J' ' of G~ ` _ I F S ~ /GQSD USE DATES OBSERVATIONS MADE I~q NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PE COLATION TESTS: IXResidence New ❑Replace ll 1 T4 !4 JCt ~t d ~'l RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ~S ❑U DS DU ®S ❑U ❑S ©u ❑s au If Percolation Tests are NOT required DESIGN RATE: If an y portion of the tested area is in the under s.H63.09(5)(b), indicate: C~ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS X s'~ 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.) r B/ 9~~0 3 >7ov /sle) B- 7 vv 33' CD 66 /Do 5. j o bpi nee ~ B- D B J so 9yo D ~o 40y r s 41.9 Z& wceJ s 1 C r 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 PE IOD 2 PE OD 3 PER INCH P- 5o 7 P- 3.. ~D D ¢ P IT6 P- f f 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 F3 03 io o~ a E ; 76 o p vo Approx. x a , 5~ ` t7~t htl/C 0 0 B0.a lend d a•• a~'. n r~ , A 9 ~ no 6E ' ' ~ o~ ~ rf s- --ra - - - p r4seoteY( Dyi c;rlf 1 Ivrv-r a SdL o fov 1~ C'E'~ ~~eU•P~ke wtt r(v~ 1"I~t6i7 i o f e ~r c- Yo~PS ~ a' pui4 tree grrrox, 5b"o 'qr~ a. d 1. 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 (prin TESTS WERE COMPLETED ON: 0, ADDRES : CERTIFICATIO NUMBER: PHONE NUM R(optional): CST SI N URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) L s~U~3 kf~ =N.e N. FUN, _ Q q MgA Ago No c r ..t 47C ~xlsnt. . SUI TAW, IS n p , r, , R„t,nxt q yma t w wabonin , o = t _ Q un E MA P& -r:;' Wma , Kid { , k Ow c ,ia ,E.. ~ .ail WV [ _ , HunwPA, MA -.i 4Yrt% Y, . r3 does Via.. w[=Fp >t, a; o N 3b }t. e;le ,E t wC t} a s~ ash A,,._. famn its (Town H W S, SM, t " f3'r r041 AGAbarn . 'I t_ Lowny SON oil - ri 1_3" 1 _n &V w n ' %mv c" n, p , rrv - - d .a a t_~ Al a.. - . W DEC t "W cv F"lrn , of th !3 p= rt. a . DES } ~ bp Os ,3 ppomwQ, k . Tip': .t -J H • Y r SC- 105 r SEP'l' 1C 'YANK MAINTENANCE ACRPEMENT Sc. Croix County ~ U Y OWNEW/lsUl LI, eLL'CAJ 0L OtJ `O ROIITK/ISOX NUMBER lf~_ Dire Number We) PKUPL:RTY I,OCAI'ION: Sae's Iuli ' 'I' N, h I TO wIt ul St . Croix County, Subdiv i-sioil - , LOt number ~i I t11pi,p r "no allll mainLunanc of Vour S ILL le system cuuLd r MULL ill ~ iLn prom turu lailure to handle wasLus. Proper maiuLenaticc cull- si5l_n of pumping Out the supLic tank uVarY Lhree years or sooner, it nuadud, by a lid uu:.cd cypV(c Lank puuiVu . What you put into Lhu synLvm can a1 1 ee:L !he i unct iuu of the cpt is tank an :i Lr eat- merit stage iu the waSLc disposal- system. ;t. Crum County residents nwy be uiigible to receive a grant for a maximum of 6O of Lhe cost of ruplacemcul. of a failing SySLem, which was Ln opuraLiuu prior to July 1, 19%ti. SL. Croi-x County acCepLud this program in August of L98D, with the reeluirument that owners of al-l new sVSLum:; arrue to kurp their systems pruperly maintained. Thu prupe'rty Owner agrees tai Submit Lo St. Croix County Z"Ilinr, a Cul-LificaL iori turns, signed by the owner and by a master piumbur, journeyman plumber, rewl-rie ted plumber ,,r a licensed pumper- vuri- fyirrg that (1) the on-SiLe wastewater disposal- System is in proper operating condition and (2) alter inSpcCL1011 acrd P"Mpinr (if nee.-- essary), the supLic tans: in less than L/3 lull of sludge and scum. Certificatiun form wi.ll be sent approxLmately 30 days prior to three year expl.ratiun. 1/WE, the undersigned, have read the above requirements and agree to to maintain the private sewage disposal_ System in accordance with the standards set furth, herein, as set by the Wisconsin Depart- merlt of NaLural Resources. Certificatio" Dorm must be e ompLeLed and recurnud to the SL. Croix County Zoning t)Liice wichirl 30 days of the three year expiration date. S 1 C NE_ ~ D AT __f1__~-_------- SL. (roix County Zurling Office P.O. Box A llammt ud, W1 54015 715-196-2239 or 715-425-13363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT S `1' 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 devel,opment.'be intended for resale by owner/contractgT ,("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 ' Section T ` N - R W Township 00 i h Mailing Address Subdivision Name Go? M c& A 00 1 7 1 _ ^J Lot Number Previous Owner of Property`' i 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 V No Volume _L 7 and Page Number - (3 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1 . Warranty Deed - 4`. -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) cart f y that aft statements on this form ahe hue to the best of my (Out) know edge; ghat I (we) am km) the owner(s) of the pnopehty de~scAi.bed in ,tUA 06onmati.on jAm, by virtue of a wat4an-ty deed neconded in the Office of the County RegilteA of Deeds as Document No. q'' and that I (we) pmenty oun the proposed site bon the sewage system (on I (we) have obtained an easement, to run with the above denct bed property, 'on the constaucti.on of said system, and the same has been duty neconded in the Office of the County Regi&e.r of Deeds, as Doetunent No. ) . SIGNATURE (I OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED