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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner O'CONNELL, DAVID E & LAURE A DAVID E & LAURE A O'CONNELL 350 MILLER RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 350 MILLER RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.450 Plat: 1925-EAGLE RIDGE SEC 07 T29N R19W EAGLE RIDGE LOT 41 Block/Condo Bldg: LOT 41 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1132/407 WD 07/23/1997 683/209 2004 SUMMARY Bill Fair Market Value: Assessed with: 48660 258,400 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.450 32,900 167,000 199,900 NO Totals for 2004: General Property 1.450 32,900 167,000 199,900 Woodland 0.000 0 0 Totals for 2003: General Property 1.450 32,900 167,000 199,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 135 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 To ❑AM Date Time ❑ PM WHILE YOU WERE OUT M Of Phone Munbers ❑ Telephoned OffirP 0 Please call aaaooas x.r~ r~ Voicemail 0 Returned your call FAX 0 Called to ser you Pager 0 Wants to see you Mobile 0 Will call again e-mail 0 URGENT Message ~ / ~y ~ n C ~T kked -k) UUJA ~t• L#-~ q(- AMPAD opereWr ROM*r EFFICIENCY* #M-OM AS BUILT SANITARY SYSTEM REPORT OWN I, 5 a i'I t ~lC'r TOWNSHIP -/-1uG(SaG~ _ G ( SEC . ~T~,4 -R W AD1)RLSS 711 ~/K~ ST. -CROIX COUNTY, WISCONSIN. ~~t~SG~7 ~j1t SUBDIVIS ION_ LOT SIZE PLAN VIEW Distances and dimL:116ions to meat ruquirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM In di( at N ,)r h rrc w BENCHMARK: (Permanent reference Point) Describe: a f/'r' S~^ Elevation of vertical reference point: to C>4 06" Slope at site: SEPT IC TANK: Manufacturer: I e Liquid Capacity: G 0 D y G Number of rinks on cover Tank manhole cover elevation: G4- 'l'ank Inlet Elevation ©G 74-Tank Outlet Elevation: f 6a,. PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump .,et Ior a cycle A gallons; Total capacity of distribution lines gallon; size of pump head; gallon per minutes horsepower 1411 ;brand name of pump and model number _ Type of warning device---. - A/ HOLDING 'L'ANK: Manufacturer _/_1f- Number of gallons Elevation of manhole cover----- Type of warning device SEEPAGE Pl'C SIZE; - --Number of pits feet diameter - feet liquid depth seepage pit inlet pipe-elevation feet. bottom of seepage pit elevation 14- SEEPAGE EED SIZE: number of lines width _1._1 engtfile depth SEEPAGE TRENCH: widt'i length /t-//+ PERCOLATION RATE AREA REQUIRED AREA AS BUIL`1'- i INSPECTOR DA'TLD PLUMBER ON JOB - LICENSE NUMBER '/1 ~ - - - x 7 IV L ~i L 3 G n ,J VII l - j C, DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN R~LATII PRIVATE SEWAGE SYSTEMS DIVISION P.Cj. BOX 7?69 BUREAU OF PLUMBING MADISON, WI 53707 [jCONVENTIONAL ❑ ALTERNATIVE State Plan l D Number: (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER ADDRESS OF PERMIT HO ERr: INSPECTIO DAT Sam Miller Trout Brook Rd., Hudson, WI I_ py BENCH MARK (Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT ELEV. SW-14 SE4, Section 7, T29N-R19W, Lot 41, Eagle Ridge, Town of Hudson 91f Name of Plumber. MP/MPRSW No.. County. Samlaary Permit Number. Doug Strohbeen 5732 St. Croix 43721 SEPTIC TANK/HOLDING TANK: /n ..S' MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV_ ITA'fTK OUTLET ELEV.. WARNING LABEL LOCKING COVER (A) ^ I PROVIDED: PROVIDED: I O (D 3^S RYES ONO DYES ONO BEDDING. VENT DIA.'. VENT MATL.. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING VENT TO FRESH ALARM LANE , JAIR INLET . YES ONO J FEET FROM S 1 DYES ONO NEAREST ✓ ~V DOSING CHAMBER: MANUFACTURER 7ING LI QUID CAPACITY PUMP MODEL PUMP/SIPHOMANUFACTIIHEN WARNING LABEL LOCKING COVER PROVIDEDPROVIDEDS ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING IVENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IL FNI,TH DIAMETER IMATIRIAL 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 JINSIDE DIA. -PITS LIQUID BED/TRENCH ~D TRENCHE MA L PIT DEPTH DIMENSIONS GRAVFL DEPTH FILL DEPTH DISTR. MPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTH NUMBER OF PR OP ERTV WELL. BUILDING. VENT TO FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV END. PIPES. LINE AIR INLET. y FEET FROM 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- meets the criteria for medium sand. TIONS MEASURED. DYES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ONO DYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES ONO OYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. FLEV.. ELEV.. DIA. ELEV.. PI PES. DIA.: ELEVATION AND DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL 1BULDING. FEET FROM LINE OYES ONO OYES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE: DILHR SBD 6710 (R. 01/82) onsin APPLICATION FOR SANITARY PERMIT ® I L H R (PLB 67) ~A~~ COUNTY mEnTOF UNIFORM SANITARY PERMIT # S T RY,lR90R6HUTG]n REl.RT10n5~~ - 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 .5' "Ph le re 61 t f- J /';jrJ'_ Rol ~tCN iG % ~`l J Olf L PROPERTY LOCATION ,E}~rY; i't61 /4 1 /4, S T; q, N, R SOW)(0 Tow t, OF: d S ~l LOT UMBER BLOCK NUMBER SUBDIVISION NA E NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED d 91 - X49 _-1/0_ 1/1 or 2 Family Number of Bedrooms. 3 Public (Specify): THIS PERMIT IS FOR A: E !?"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. A+'Seepaye 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: VZ1r e v 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): r ` O 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 re: MP/MPRSW No.: Phone Number: Mp_!~73) j Plumber's Address: Name of Designer: P w 1 f/~j 0 =i t Dori : jh 17 00 0!u_> COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fe//e~~: Date: ❑ Disapproved X Approved ❑ Owner Given Initial 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. I . y Form - S T C 10 0 ,C Owner of Property- Location of Property ~ u, Section ~ T ~ N R, W Township - F Mailing Address --L Cr/ ~s✓~ it/r5 7 v /C Subdivision Names Lot Number ~`-'p\ f' } Previous Owner of Pruperty7-1 Total Size of Parcel f~L'-L-,~ 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 legal 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. ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an Basement, to run with the ) above described property, for the construction of said system, and the same has been duly recorded in the of t Office he County Register of Deeds, as Document No. SIGNATURE OF OWNkR SIGNATURE OF CO-OWNER (IF APPLICABLE) itl-1~~ ,,'~1✓, DATIL SIGNED OATE SIGNED DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, GG DIVISION BOX HUMAN ~REDLATIONS - PERCOLATION TESTS (11J) MADISON WI 53707 11 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: OWNSHIP// LOT NO.: BLK. NO.: SUBDIVISION NAME: SW '/ate'/a M7 N/R/9 P(o T js 4 ,W l.-dL/- e_ COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: USE DATES OBSER ATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ~ew ❑Replace 10 .9 RATING: S= Site suitable for system U= Site unsuitable for system d . Y A.., "6 S,`l' t,4" CONY SNTIONA . IMIKOUNSD: ❑U IN-GROUND-PRESSURE: SYS~TE -INRECOMMEND SYSTEM: (optional) If P~erJcolation Tests are NOT required DESIGN RATE: If any portion the tested area is in the under s.H63.09(5)(b), indicate: Flood lain, indicate Floodplain elevation: PR FI E DESCRIPTIONS BORING TOTAL/ DEPTH TO GROUNDWATER-CGS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHj+- ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- Or 10(o.Y' . C e S 311n s Cs 01 B- AAMe- S-1 7 '91, /CS B- r O Set /.,/e CS r S B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER ';~.~--r...~ AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PERINCH P- / ,1" '410 v 33 3'L 3./Z- P_ p L) / L t/lam P- P_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distant. gescribe what are tbslbori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings "nd the &tQ tion'and percent `I of land slope. SYSTEM ELEVATION _ /o% Y ' Zed M ~d z ~A~'au~•-~ ~.3► w~ ~ /~/~.M _ ~`_s 7t~i.~ l1Gr ~ ! e- / jV ~4CcaFtu a~vrSa e. -~a` C?n1 ! p f N 1 I l )7 bUrzs (AA4Z ~e_) b Per cyCP-sfA -'7 J-" 614C 0.4-Z19 40V 9-/0&2 v Slo/a SoK r k.0 514 C, Ir e 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 inistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. print): TESTS WERE COMPLETED ON: T CERTIFICATION NUMBER: PHONE NUMBER (optional): -2 14' S77Z C ATURE: ett'.. € d :3 ,Ck e . eta yw, Mimi , O W&W i h ,S t -i~ ar5a4 "ret_a W 3 My =r" uatt.. ho `€l wiv ;q a wr, wr or £„om e r at ;trojecw sriC't„ ,,}£d7"?r°; c r C:f; as MOW; AL- HE SY T EHIS ARE RULP5 OUT 17 m3_= ON I CisND ? ='`lS "hSE un ? the - € bi 1 i<UO StaOWn wt[ ing pr €tHe cks ilj..-€.:C=w <@1°€ l cor13(➢ii:[:ing the ELY€?(; j3idn, ;°'.t;, A LECi 1` ~ a" C {a,... t.€ i;at:;£,. artcly locating L3)iS~ '€d zt ,clt,r o: " S'cal se dw,.. Sh . € ° .,-a9 r,=_nr tea, ia'in( we 't aa., nar r„"v _ .',i _a ar°„ F ._ie e {.ate t7'. shvyv~ wtd a€ K?f?, nmiv:°t; cc A! am Moro V . ° OS as a r <am, a..[-.k, t - 7 sd pla t "hr. ti., , T, (-'o, ie ao t,«S° 5e-, ePI Y- M4 if appoll woo; H On k ;t? m €;.(c: no Wall as a€,..w qI Eil E'it ,,x°W (fms in <,€:tyc ru at:i:?. (v.A m the ap p iaa-t box; Sq-t W ; Q w d p1my ymr Catr vA toy. wd ym 1. AaF€£'i-. n,.,.'e0r; Wre u rapq ,t'm! €l.st:Eo.mn, as re TWA At ..L `Oit TESTS € t91S-F HE FILED ~ r4 I}TH THE' SOH _ 'woo, sycow'' boon won W) OR WnM' 1w') S -1, Wove! iunuer LA Qnswin, a & v Hioh GO a w Mod Peru 14(ohoicea Ray, W~-'iwo Sand IN V%' 111 .7. ° . BWWa Lowy Sam! AnyK Le" `'w SHQ Chy Won Plot IOWA, tray Day y c E 3_ frn~ 50 RAW,, khowum a,a i va e t't,?c7s,: in r u,:t stop a, a. cu 1~{ a 5-ai13"Ce,t iJ mill. Tho . , mm't7 wo 11145c`7 a"t"P}€€_@c~ Inju € 2 °kw,., of th. ..,e as 'a;_ W id t);r,a" to n-ro r! =.°t:e. £q,='};".). Q jai:,., t=,-£ to 11 a and a neaw ca { E, . n 5, s€r„m d ow .EN)Itl(=? (.f h t .fara3ao€ 90O i 4 Z Q ti © ~ to N T !t! • ° -d va o o - rd 1% AS~ Tri - CO P 76 eRl` p t~ LA w 3 tr ~ 4 N P o o , 00 c ll ~ n Via s ar -t'' (14 FL S ft- r b 7TI ~-t- ~l H -tf i P ~ a 5 -b r i J ~~r p fl ~ j~ P V" ~ Y O ~ 00 1 rs, j L c a 'i A i H ' c _ -c r4 -00 o' t t i i i 2 P` M d d 4 L4 1 I ~ a, ae o ~ z M O ei ICA ~ ~ c/7 tJl H ST C- 105 r ' H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d 9 H OWNER/BUYER ck r r c-y ROUTE/BOX NUMBER" Fire Number CITY/STATE ryy.I&`_.,c~~,~ w ZIP J yC) 14, Section T. N, RL _W, PROPERTY LOCATION: x,1,7 ~4, c _ Town of St. Croix County, Lot number Subdivision 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. yo E I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro 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 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 Dat v : c< < v c_• c .k--~ Location of Property SectionT 2`l N - R L W Township Mailing Address I>, c,- Subdivision Name E /.I- c -vt Lot Number , Previous Owner of Property 1~ d 5" Total Size of Parcel (;n Date Parcel was Created 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 Z C't~ / 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) eeAti,6y that att a.tatementa on thiA 6oAm aAe t&u.e to the beat o6 my (ouA.) knowee.dge; that I (we) am (aAe) the owneA (s) o6 the ptopeh,ty des cA bed in .th iA in6oAmati.on 6oAm, by viAtue o6 a waAAanty deed %econded in the 066ice o6 the County Reg.i.e.teA o6 Deeds as Document No. , , ; and that I (we) ptea en tty own the pnopoa ed 6.c to 6oA the 6 ewage dizpuat 6 y6 tem ( oA I (we) have obtained an ea6ement, to tun with the above de6c4i.bed ptopen.ty, Got the con6tAueti.on o6 6a.id 6ya.tem, and the Game ha6 been duty %eco&ded in the 066ice o6 the County RegiA teA o6 Deed-6, as Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED