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HomeMy WebLinkAbout042-1084-20-000 o d f 3 d a d c 3 (D '0 T 7! 4-t F~ T I m \ 1 3 3 Z P • Z w o n O d uNi O c0D O N N N C) cn H CL = Z a y O d j CO 0 1 ` C O S co O C N Q? O N O N "~~~•'••1 En -P. Q , LS O m 7 n ? 7 O CL p N O O 3 3 H 3 0 0 c o j II m us CD D m m ? cn W o C Q N `D I s CD N) CD Off', .p ~7 , O H m 7 7y t o cD m I n r cn o (n A co cn N ° o' (D 77 ((DD rrt V m L=J r j CA ~J H IPA. x A o z o ~ ~ ~ ~ ' II ar4 n H r o 0 0 ~ cn (n Vl w' j CD (D l1i v N Q -0 o a N W 1-r 00 O - CD y 90 m \.o x rn m C m(D O- o m ~ m c s :3 3 m z N _ N N b ` 0 n - D co o - a m tai tr m N rQ ON CD CD N O N m w m m N CL W 3 Z{;-. Z O O A Z O 7J O^ 7 Z O co M co ~ a A n rt = U) -i w CD K r• W v m to f] (D O cD CD z o 0 3 ~ o " 0. F- l O y (D 0 'o w CD X Da CD C a E m CL CD N N o_ m z a :3 a CD m m f fi CD v A O A O O ti d j in lv CD O ~ O p V O a ~ A O I C tNn m O EA O ~ O o :E 'O 00 CD Form- ST C:104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP L(!;~;"~y SEC. .'-3 C, T ~N-R W ADDRESS I~ L / ST. CROIX COUNTY, WISCONSIN SUBDIVISION' LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM `\j t~ V , INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used l Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used:- Tank manhole cover elevation: Tank Inlet Elevation:Tank Outlet Elevation: /7 Number of feet from nearest Road: Front,O Side,Q Rear, feet From nearest property line Front, 0Side, 0Rear, O feet 3 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: s 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 ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: 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). 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: Inspector: • S " - Dated . _ . Plumber on job: License Number: s 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING P.G. BOX 7969 MADISON, WI 5:707 ~ fktCONVENTIONAL ❑ALTERNATIVE (If sPlne LD. Number. (lf assigned) F-1 Holding Tank El In-Ground Pressure ❑ Mound TANK REPLACEMENT NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION DATE. Graham Meredith RR4~2, Box 171, Roberts, WI REF. PL ELEV.. ICS' REF. PT. ELEV. BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. SE SW, Section 30, T29N-R18W, Town of Warren Name of Plumber MP/MPRSW No. County Sanitary Permit Number 3258 St. Croix 58910 Henry Nechville SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER pROV ED PROVIDED YES ❑No ❑YES NO PROPER WELL BUILDING J VENTTOFR ESH BEDDING: JVENTDIA.'. VENT MATL. HIGH WATER NUMBER OF ROAD. LINE7 AIR INLET. ALAR FEET FROM ICJ ❑YES NO ❑ MYESNO NEAREST 'Xf DOSING CHAMBER: PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER MANUFACTURER JBEDDING. LIQUID CAPACITY PUMP MODEL PROVIDED: PROVIDED'. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING (VENT TO FRESH LINE AIR INLET'. (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO NEAREST LFN(~TH ()IAMETER MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall c ase until A11gIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LIQUID TERIAL' INSIDE DIA UPITS DEPTH BED(TRENCH WIDTH LENGTH NO F DIS SPA COVER T ENCHES' PIT DIMENSIONS NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH GRAVFI DE"r FILL DEPTH JUISTH PIPF DISTR PIPE DISTR. PIPE MATERI L PNOEDISTH. LINE. AIR INLET. BELOW PIPES ABOVE COVER ELEV. INLET ELEV EN FEET FROM 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO OBsERVATIONWELLs P ERMANENT MARKERS. SOIL COVER TExruRE ❑YES ❑NO ❑YES ❑NO SEEDED MULCHED. DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED CENTER EDGES. ❑YES LINO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER WIDTH LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. PNOEDISTR. DDISATR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV. ELEV. DIA. ELEV.' ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS ❑YES ❑NO ❑YES ❑NO WELL NUMBER OF ~FPROPERTY COMMENTS: PEANENT MARKERS: OBSERVATION WELLS: FEET FROM ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Re in in county file for audit. Reverse Side. SIGNATURE ? ITITLE DILHR SBD 6710 (R. 01/82) CATION FOR SANITARY PERMIT F7InOJ mnssn APPLI DILHR (PLB 67) COUNTY menT f UNIFORM SANITARY PERMIT # STRY, LRR0n 6 HUMAn RELRTIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: VILLAGE- 1 / 4 S`-L' 1 / 4, S Ta',N,R/ E(or W` TOWN OF Guc- LOT NUMBER BLOC MBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED ?7_1 or 2 Family Number of Bedrooms. ~j Public (Specify): THIS PERMIT IS FOR A: •s ❑ New System Tank Replacement LIF9 epair ❑ 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 C t,,isting, 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 ' 41 Manufacturer: / S Jr c1 iYl G / - IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total # of Prefab. Site Steel Fiberglass Plastic allons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber rr Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 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): Signature: MP PRSW N.o% Phone Number: c Y, Plumber's Addr s: Name of Designer: 1 ~u^ S COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: F,ee: Date: ❑ Disapproved *&t44t t / (jt/ ❑ Owner Given Initial / ~~p o 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); 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. Form - S 'r C 100 Owner of Property Lr ra A c~-`yr 121 zt-t~i i .Location of Property S4:: Z -,Lu ~4, Section `34 T 2`3 N R /fs' ~1J Township . / 'e"j- v r F Mailing Address ~2 l~~x /7/ Subdivision Name r Lot Number X `e AIA= Previous Owner of Property. Total Size of Parcel Date Parcel Was Created Are all corners identifiable? /Yes No Include with this application one of the following: .Certified Survey Map .Deed .Land Contract, or .Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. S Y2-1 ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. 1• SIGNATURE OF OWNER SIGNATURE OF CO-OWNN~ER (IF APPLICABLE) DATE SIGNED DATE SIGNED Form - S T C - 1C. ONE. AND TWO FAMILY The existing system must be inspected for compliance to bedrock and high groundwater requirements of the code. This, in many instances, will require a soil test to be conducted by a Certified Soil Tester or an on site by this office. If the existing system does meet minimum requirements for groundwater and bedrock depths and if it is functioning, an addition can be added in most instances without updating the existing system. If the existing system is utilized for the addition, every attempt should be made to locate and reserve an area which is suitable for a code complying replacement system for when the system fails. If the addition will substantially increase the wastewater discharge, the existing system shall be replaced with a code complying private sewage system. ik, It C, ep- 3, 1/4 pw 1/4 (Subdivision & Lot Section Township Rural Route # Address Post Office Zip Code M(We) /V 14 plan to (build an addition to, remodel) the building at the above named location. The present private sewage system has been working satisfactorily as far as disposing of wastes. If the present private sewage system does fail, it will be replaced with one that is code complying. A J (2) (Owner's Signature) Date Subscribed and sworn to before me this -i / `4 day of AILIW ,66 - 19 y Notary Public County, Wisconsin My Commission Expires ciU,~, vJ ST, CROIX COUNTY (County Authority) Plot plan attached (show -location of building addition to drainfield and septic tank). Include soil testers report form. H • H 9 ST C- 105 r r H SEPTIC TANK MAINTENANCE AGREEMENT C St. Croix County z 9 H OWNER/BUYER c? IkI ROUTE/BOX NUMBER !I 9 .7( -Fire Number CITY/STATE LIP PROPERTY LOCATION: ~4, S 4t 14, Section C, T ::2 N, R ~WA!, Town of LSt. 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 pmp r. 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. 0 I/WE, the undersigned, have read the above requirements and agree 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. ) j >(S I G N E D %7 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. n J -1 c • v;w~~ an m° 0 o N a 0co~~ccocoo~A 1 1131ZS~oaiNo~ n v n o0, w~j0wA _ m m a 0 0-0 n O N m w 0 3 a O 0 wc0 t0 o cc 0 c o =C 0 i c SI) c N 3.Zco cle- 0 ~ v~ f 7 ° w N SD c CD M m o~ o~oCL ° w to o`OO-.-ov < m c o Dc n o N ~r 0 0 ao f p 0 10 ID cna N N Z D O :3 CA N 'd W W f N. Z w 1` N mC 2~ CD mm m m?a D D M (A a~D oNC° ° m QN ?ac°c w N a ac0~mf C 3 ° v (CAD So W°? n v cg N m-' ~N _ o =st or 0. w `c cmi c to -1 ell, Nom CD - cco~cmnw 4 w3a cC7 m `t a O (CID) C CM C ui 7 w m CL 06 N 0.0 E; ID Cl) CD m u► o G7 coo ~ o a c °m o N 0 N m°C 0(a CL a ~-imc a0~ caw mv.yr0 CL cm Q o c m o o° m map„3 a~ 003 3 ate-, a ° < CD z coo O c 13 oler S11,41_,47-lo v To svgs s r,'fA)%ArE-- svi r his;%:Yj or- DEPARTMENT OF REPORT ON SOIL BORING AFETY & BUILDINGS INDUSTRY, ~ DIVISION LABOR AND PERCOLATION TESTS 5~ 'V E9 P.O. BOX 7969 HUMAN RELATIONS 4t')- CT ZONIN 84 MADISON, WI 53707 • (H63.09(1) & Chap 43?0 ~ j" LOCATION: • SECTION: TOWNSHIP/fYrb'-1r: L 0.:BLV SUBDIV NAME: SE - 1/4 1/ 30 /T,29 N/R/P E COUNTY: OWNER'S/•!~ NAME: MAILING ADDRESS: s/-G,o4 A~_ ~USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 2 ❑New ❑Replace 10 f /3 Q~ RATING: S= Site suitable for system U= Site unsuitable for system 7C~ 6 7 6~~f,=-- 5_011S / - C7'5 CONVENTIONAL: MOUND: IfV-GROUND-PRESSURE:SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ©s ❑ u s❑ u, o s❑ u ❑ s ~u ❑ s a u ~a~vv~yTi D.U,~/ S~S7/E~S F rcolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the r s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ~F PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B ' 10A) C' S tvi dpt~ sySf.,., L.iiES W7 --A p oX. s 70 .0 DEF B- G o v f134Ck_15`06'- P/ 'f / 47X6,5-0 x 7,;e B -,Ole :v E66L- 42. Al ReO X - ,J w B- 6g S 04-D oar Na s:,PE-W +-t 611C /7b C- P/`f . /Uo ~vi1~ENC~ oc w- D-#e Z ' B- T-PE MEtiV-r rf je EA ~ -fo J~c 11i, ReA_,fie L-1- c 0 14/reR . PERCOLATION TESTS U TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH P- P- i So%L5 j Am tD' To VYe 4-y15•7'iN S S F.y E- P- vGcv COD C' L% ,V o P- D S v 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 Don the plot plan. Show the surface elevation at all borings and the direction and percent T- of land slope. ~ X/ sr/ V SYs7(- fps A P / R 0 X t f 9/ 7 SYSTEM ELEVATION 0 //Ole2.3 UEaT (3M s Tod, OT f,kuc GrT- ; 6fauhTlc x. _ /0e) 0 Fr SOS ecre 1 P~G`R MF,tanrf'~" OF h6A4 s 7 2oiJ~~ (fir. N . e _~+Pp~ws e~• AG $kes' nexsept 36, 4o ce,Je ~D ~ 6xrsr~,v~ ColtApsel.- sari/E- 41 CO F.+Pont /3 GO~r 13trk/v- I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: R1 JA A&AIP, -P HOMESITE SEPTIC PLUMBING C 7 • 13 - 4 ADDRESS: 11L nu., N, WIS.16 CERTIFICATION NUMBER: P T6- E NUMBER optional): WIS. MA ROBERTULBRICNT SS t~~ PS 'WIN N. INSTALLER &_66 GNER LI . CST SIGNATUR C NO. 00663 ~ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - V , bp a cumphs, am! au, i1pk i' qcd ti., i`cscripik31. 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PV ~ Wy BE K! time (am W) Bedrw-'k x, fw u , sl ^it`. .3 _ I W) SS su nslFCt7 T'!° (heal ,1 uMi 3" LS - ? €.i tone sand HG WY - ! 1 Co itif ""stt`i , , ` S=WyJ Lo,mi r. ~ Ins i W =,f. i i ? , To Wan! - fill Gy Day Knin °f °a., ~ mss. n'; ,,r r ' F 'yr Soy c f,t.,, s.;77 - Sax: ~rrr - t i i.~ lest€_(, sl, f a. it lest e[.~?tsri iS TV a.,. "r a, s,- ,a' g M. 'I It d r-nar(.S q,. est ii cation of this &I inSt „y the {[r 4d paw l.' _ nOt 5.,tnj.x,=. . vm .i x. „£s' t>, own k, it ;?7I1'm x[, WO And _ ^xrM Ar, ,'w ~n a~€a, !W AT n { "O wv Mme My iAMC)F Y 5$ C cIN is 46 k J s I rL-~ - /en.c i I O 19 IDOn t Form - S T C 1001 Owner""of Property ,Location of Property ~4 Section 'f N R W Township Mailing Address Subdivision Name` a Lot Number w~ Previous Owner of Property Total Size of Parcel Date Parcel Was Created ` Are all corners identifiable. Yes No S 1 Include with this application "One/of the following: ~ l Certified Survey Map .Deed Land Contract, or .Other Legal Document which escrib' s the property PROPERTY OWNER CERTIFICATION 4 ' ~0 I (We) certify that all statements on this form are true to the best of my (ourhl knowledge; that I (we) am (are) the owner(s) of the property described in this` y information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above;described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. SIGNATURE OF OWNER / SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED