HomeMy WebLinkAbout030-1085-50-300
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 600204
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village Township Parcel Tax No:
Daniel & Bethany Weiland TOWN OF SAINT JOSEPH 030-1085-50-300
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/oo . 3:5 Q Z_ 30.30.19.310B-30
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Z~ MOO Benchmark ~J J/~
• 7 7
Dosing L Alt. BM c f. f.63
ion ✓ Bldg. Sewer /r a 3 ~4 b
Holding St/Ht Inlet
133g 9~• y
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/Ltj WELL BLDG. ent to it Intake ROAD Dt Inlet
Septic >56 / Dt Bottom 7'
Dosing I / Header/Mar
A- 144
Aeration Dist. Pipe 9eaQ 7S
Holding Bot. System 11
, / ~ ~ $ ~ / _
PUMP/SIPHON INFORMATION Final Grade
Manufacturer ~t s Demand St Cover , ~
1 M "r ~•1LA-
Model Number i ~°r~ Its 4 Gj
TDH Lij, 10 Friction System H:adA TD t lTi_l y/3, Q~
Forcemaiinn Length ~ Dia. Dist. .tt`o'Well
Z y.ok1 V
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenc s y~ PIT DIMENSIONS No. Of Pits Inside Dia___ Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactu~ rreer
INFORMATION CHAMBER OR J- A l
Type Of System ` UNIT Model mber:
Gary✓e ►s~d~ yZ6
/q}-~cj~ ✓S
DISTRIBUTION SYSTEM 441
Header/Manifold Distribution x Hole Size x Hole Spacing Vent Air Intak&
Pipe(s) . v
Length Length Dia Spacing
Ib 4.
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes F No es ! 1 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 362 VALLEY VIE L E4 ilo" L,/ I sG (te, s
1.) Alt BM Description A~6--I
2.) Bldg sewer length = Z
- amount of cover ,
Plan revision Required? Yes No I'L g ' 3 /
Use other side for additional informat n. L I 4
Date -
nsepct Signa Cert. No.
SBD-6710 (R.3/97)
ppopffly owner
ty
S La•?6 L; nG y a>ac 1 E€ t ;=k1l€
7,
Eat
gy. AP
V M r
A5`_i_:"V. a{1 aa~..sL~i.'
°r ~6 t-RO),\ iJ7irltiEE~~J
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~Indnshy Servt<xs Sion County
1400 E w ve JT C' R~tx
sr` 1
r I : P• San ILI/l1itary Permit Number (to be filled in by Co.)
M 3707- 162
J' _ Dow
`FSw t
Sanitary Permit App icaen o~ o State Transadiom Ntmuber
in accordance with SPS 38321(2), Wis. Adm. Code, submission of this form the ~;bvesnmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for are submitted to Project Address (if different than mailing address)
tIN Department of Safety and Professional Services. Personal information be used for second9o
LU purposes in accordance with the Privacy law s. 15. 1 m Stets
I. Application Information - Plow Print All Information G V 1 Cpl/ 7
Owner's Name Parcel #
W I LiN17 -5c
,qN iEt GTHAfi,
Owner's Mailing Address Property Location < o . 30. i • 3) _
i ( 1 71 t° FA,V Y bzEEK Govt. Lot
ity, State Zip Code Phone umber 5 i V y., ti L 'b Section 3
L•~t171 ~C L LIT ~i -t 5N C' 13 ~ ~ (circle ~
T 6t, N, R~E WJ
Jd Type of Building (check all that apply) Lot #
Family Dwelling - Number of Bedrooms Subdivision Name
i or 2
{
)4 %001,
Per SVb11Mii4tA Block#
❑ PublielCommercial - Describe U Im Dote 0 s City of
e
State Owned - Describe Use CSM Number $Uq 60 ❑ Village of
i-muiI n I tells q 1 4-Iq t +Iq 1 hAn z l a 1 ~ jn L own of
M. Type of Permit. (Check only box on line A. Complete lipe B if applicable)
New System laoemert System ❑ Tivatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Trar> *r to New List Previous Permit Number and Date Lwied
Before Expiration Owner (3) 3 t x '762'
HDevice: Check all that apply
Pressurized Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
1
' ` a+VV"
❑ Holding Tank ❑ Other Dispersal Component (earptam) ❑ Pretreatment Device (explain) IQ 171 IA T1 I ~y
V. Dis KTrea 'Area Information: Owe- t4
Design Flow (gpa Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation t
y
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units E Uo
d+
New Tanks b istingTanks / d o r u ao
Y- J D P. U ao v, W W 0 P.
Woo - 000 CS~h ~I
Dosing Chamber tSU - )-,;V
VII. R,es nsibility Statement- I, the undersigned, aasame respandbr"6tyr' lation of the POWTS on the attached plem
jMru Plum ame (Print) Plumber Signature Number Business Phone Number
E ci 7 r5- za 3 LiLi 44
Plumber's Address (Street, City, State, Zip code)
VIII. Conn rGmat use On
ed Permit Fee Daft Issued Issuing Agent iSignature
Given Reason $ ! S
IX. ConditioY>~IrOkb~soes for Disapproval I • W)p~GV/t~'~~o3y A~~ M
1. Septic tank, effluent filter and , ~~nCll~dn S 1/I
dispersal cell must be serv_iged I maintaingd tp~~
as per management plan provided by plumber. l'_ /
2. All setback requirements must be maintained Ii. eCe~~/
ac per app Attach to eamptNe pans for the sysses and sari to cemty an paper nit ias ffia. 8 ra x I I tech!; in size J
5.~ wet
SBD-6398 (R 08/14)
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12)
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Filter Specs Soil Evaluation Report & Site Map
Tank Specs WARPvVO 1)&C to
1 "A> v f l i r:,A i( (1 ` r 7 t `P'7 iC_ ;A A C, -ZVE j OL
Project Name / Description
Owner Name(s): _ +-XFAi -L 4~ &-m ANY IA0L_ i t_fl Phone: - -
Owner Address: art -t l v eR~ r, RL.,~ ~t ~ co ® caw , w A Zip: -514 t i
Project Address: _ '3tr z- e,°A LLCy UGC-v,) -FP A, -
Govt. Lot: 5W 1/4 of A)& 1/4, Section -;SO , T 30 N-R (41 E Qor W
Township: 5T_ J~,>>tr~rt County: 5T_ C'.iic~X
Project Parcel! 1D#:
E _~c' iC ~ ~Ce C(
Designer Information
Designer Name: MARY JO HUPPERT Phone: 715 _ 426 _ 1775
Designer Address: 28497 King Arthur's Court, Danbury, WI
E-mail: hollisterdesi9n@outlook.com
IsJSJJJ
License Number: 1859-007°
PAM J0
Remarks: /RT •
•
RIVER FALLSj
W1 00"
;
Signature: Date: al 7
Original signature req ired on each submitted copy.
Page, f
pmpeygy Owner D-AUi Otis s; iLAK
-lip - 6oft
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PAGE 4OF5
GRAVITY-DOSED
SEPTIC / PUMP TANK SPECIFICATIONS
4"0 Vent Pipe (No Scale)
>fu tt tram
Building Electrical must comply with
1 r Min. or 2.0 It above SPS 316 and NEC 300
Established Flood Elevation Weatherproof Extend manhole riser as necessary,
(typical) Approved Junction Box
Approved Locking Manhole
IMPORTANT: Verd tap with Waming Label Attached
(typical)
Anchor tank(s) as necessary Conduit
pursuant to SPS 383.43(8)(g) a• Min. or 2.0 ft above
Established Flood Elevation
(typical)
Airtight Seal
Finished Grade -Gate Valve!
*~uick Diswnned
CAPACITIES @ ( t'> gain
4
Depth (in) Volume (gal) Watertight Plug
I
A ~7 5 i,' ~f ~ 7 5L ~ ~ 3rGl * ~ Min. Depth 1-12L in
(below frosdlne)
B 2.0 o A Watertight Gasket
101 r '6 5t) Alarm
' [cl Pump PUMP-OFF
*Pump Tank Liquid Level = in - ELEVATION= ft
check
valve
Force Main Diameter = r in o Concrete INSIDE BOTTOM
Block ELEVATION ft
Force Main Length = !r ft 3- Approved BeddMg Material Beneath Tank
Important: Bury force main below frost line or insulate
as necessary pursuant to SPS 382.30(11)(c), W.A.G.
[C] Total Dose Volume (TDV) = Sy. 5C gal/dose (4'lO)
L (<0.2X design flow- NO DRAiNBACK 4 check valve)
-57 r7
Vertical Lift = ft -1oz~ -T-OH
PUMP TANK: SEPTIC TANK(S):
Volume = 41 --a t=3 gal Total Volume = 1. Ui a (1 gal
Manufacturer. 0i I cc;" Z-- r"' Manufacturer(s): j<
Pump Manufacturer. L L L L`
Install approved effluent filter at the septic tank outlet
Pump Mode{: t' `P 1 (see attached pump curve) immediately upstream of the pump tank inlet
Controls/Alarm Manufacturer. 5j~ F4fc.4jpc Filter Manufacturer: ,/3n,r i l t~ i c z
Controls/Aalrm Model: A6 1...k, K A 4 .r .
Filter Model: 6, F- - - !b
Float switches containing mercury are prohibited.
PAGE -47OF 96"
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-gravity system shall be responsible for its perpetual operation and maintenance
pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this
system shall be considered a human health hazard if not maintained in accordance with this approved management
plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatina Limits:
Design Flow= z/.56 gpd; BOD5 5 220 mgL-'; TSS 5150 mgL"; FOGS 30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.)
o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Effluent filterfs) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. pReport any component failure or malfunction to;
Name of individual or company: T1met'~"' N &I 'c Nj Phone:
Local government unit S CRUX CGU 'rY CG.AkA"/ 4 ne%;zLCP- Phone: 7 =3SLI
Local government unit address: f jU L~Su. i ZIP: _ U I l,-,
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
Wastewater
METERS FEET
40
1
PE~~ MODELS. PE31 PE41 PE5
5.. - HP:.33-40-50
35
10 f
- ► 2 GPM - , -
30 PE ,
1 FT
_ f
PE31_
x 25~
V
Q
Z 20
-
J
15 .
t~
O
10
i _
0 0 0 10 30 40 50 60 70 GPM 80
0 5 10 15 m3/h
CAPACITY
PERFORMANCE RATINGS
PE31 PE41 PE51
Total Head Total Head Total Head
(feet of water) GPM (feet of water) GPM (feet of water) GPM
5 52 8 61 10 67
10 42 10 57 15 59
15 29 15 46 20 50
20 16 20 33 25 39
25 0 25 16 30 26
35 8
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m wLP1000 650-MR OEM CIICIETEDRIN A'BY.1• REV NO. DATE
O m
z SEPTIC MANUAL W3716 US HW IM MAIDEN ROCK. YN 54750 DATE: JANUARY 2008
REV. JAN. 2008 800-325-8456 FIZVKP1000 650-MR
(~~ILft1U1J ~ ~ft,'V
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I The Quick4s Standard Chamber fits in a 36" wide trench v
and is ideal for curved or straight systems. It features the
patent-pending Contour Swivel Connection- which permits,..
turns up to 15°, right or left. The MultiPort- endcap allows
multiple piping options and eliminates pipe fittings. The -
chamber's four-foot length provides optimal installation
flexibility.
• Advanced contouring connections swivel up to 15°, y
right or left
~t
• Latching mechanism allows for quick installation
• Four-foot chambers are easy to handle and install
• The Quick4 Standard Chamber supports wheel loads of
16,000 lbs/axle with only 12" of cover
• Certified by the International Association i4~lrr~
, _~rt•~
BAr
of Plumbing and Mechanical Officials (IAPMOj
• Tear-out seals on inlet ports provide a tight fit to the pipe
• Eight molded-in inlets/outlets allow -
for maximum piping flexibility ,
~ `mss'`;'.. •
• Eliminates pipe fittings
• Fits on either end of the Quick4 Standard Chamber
APPROVED in
Vt1E:fL~ItiD ~ l,7Ya'
Quick4 SWOrd Chamber
0 =
u
w M9620 HIM! a~ M
34" - -4Rn
(EFFECTIVE LENGTH)
Muffort EWCap
v v`/--------ter
r \ rn t 1(r t l r i s:
rls -
-1 IL
FRONT VIEW SIDE VIEW TOP VIEW
Typical Tnxlch View IWIL.TRATOR WAT6t TECHNOLOWES S'rANIUM UtYy M WArftAwn
(a) The swxbxad iNeWity of each dwitier. endcap and o0w accessory rraruFacinred by
ktfltrator rUmis evhan installed and operated in a afield of an onsite septic system in
NATNE BACxfal ropy accordance with Midatar's instructions, is warranted to the original purchaser (-Holder-) against
defective materials and workmarsltip for one year from the dMe that Ite sepW permit is issued for
the septic system contain" the Units: provided. however, that d a septic ptamli is not regmW by
COVER BY appbe" kw. the warranty period writ begin upon the date that installation of the septic system
DESIGN
commences. r To em me its warranty rights. Holder must notify InAftrator in waiting at its Corporate
fleadgrualem in Ofd Saybrook. Conrw*cut within fifteen (15( days of the aieged de act hrtabator
%*A supply a Units for Units daterrnirsed by Infiltrator to be Covered e' 1 WRT Warranty I or s liability specifically excludes the cad of removal and/or n this
Linked
t { 1r
stalWion
of the Units. CME THE LIfAfTED WARRANTY AND REMEDIES W SUBAARAGRAPH lei ARE EXCtd15NE.
Tnarch+n swtctntr; wErt THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS. INCLUDING NO
IMPLIED WARRANnES OF KfflW. iANTA61lfiY OR f r ESS FOR A PARTICULAR PURPOSE
Id This Limited warranty shall be void if any pert of the chamber system is manufactured by
anyone other Thar Infiltrator The Linked Warranty does not extend to nciderdal. 00115 sandal.
$t7e 34"W X 53n1 X 12"H special a indkect damages. Infiltrator Shall not oe Bable for pernalties a iquidated damages.
including loss of poducbm and profit, M6or and materiels, overhead costs. or other tosses or
(864 mm x 1346 mm x 305 rmn) expenses i nc nd by me Holder or arty fhRd pally. Spey excluded from Limited Warranty
coverage are damage to the Units due to ad wy war end tear. allerabW aCCIderIL misuse.
Effective L0198I 48° (1219 mm) mouse or neglect of the units. the Units bevy subjected t0 vehicle traffic a other Conditions w hch
ere not per miffed by the istaiatim nshuctims; f*xe m maintain the mdnnmmn ground covers
Ltwner Haft 8n (203 mm) sot faih in the 9>51a0OM n*Mhott5 the plaowat of improper materials irdo the system
contardny the tnutx &AM a the units a the septic system due m n,proper a" or improper
reaae osal, a improper operation: or ay cow
cw.i,.~ capacity 43 gal (163 Q sizing- exc~ae -A- usage. improper 9 dsp
evert not CatisW by Witrntor. This t sited Warrariy stall the void d the Holder raft 10 comply
Invert HaPt 8° (203 mm) with all of the terns set (oft n dlis Limited Warranty. Fwther. n no evert slats Irdarator be
reSponsUe for arty loss or damage to fire Holder: the Unis. or arty trued party restYt V from
w sbWbot or L or iron any prod kbk Mims of H*Ier or any t wd party. For this
Imbed Warranty to apply. the mitts m st be estakd in accordance evkh all alt candy min
re*M by state and local rxxles; all o0w applicable 131K and trtlitrator's iser{aeort istlucoo s.
(0 No represergative of Itfilbator has the adtwdty to charge a extend this UmMd Wararty.
NO Warranty apples to any party other VM1n the Original Holier.
r tan Pack ftoad The above represents the Standard Limited warranty offered by Wfdtrator. A Muted rnmber of
states acrd counties have di faent warranty regniement& Any purchaser of U nits should contact
Old BSWbFCW CT anc 76a 06475 knfitrator•s Corporate Headquarters in Oid Saybrook. Connecticut. prior to such purdnase. to
~ 60
- _ - - 860-ST-itl~ • t'ax 860-Sr 7-7001 obta n a copy of the applicatife K'a►arttU'. aril staWd cam raatf tlat wraranly prior to the
_ 1-SOG-221-4436 pum3ase of Units.
www ard"tratorwister mm
td.&. Patents: 4.799.661: 5.017.041: 5.156,.116; "36,017: 5.401.116: 5.401.4sw SS11.903: 5,716,163; 5.511.77a: 5„ 839,873 Canadian Patents: ,,329.959: 2.)04.564 Omer paters perWira.
I "baby. Equagaw Q icM. and SK*V*xW a t ragiste ed trademarta d a Abalor Water Technologies. khfahator s a reg stered tradaniark in fiance. kWPorator WatarTect rgbgiss is a regis<eM
trademark in Mexioo.
Cantacr, Miuoleacfang. Po Yluff ChambL+rSpaeet- etcr4P'ort. Pustaclc.0uiddaR. Oeid , Srnaptnec ant Spraighnpgc are haderrurke d krfL4aRar 1rYaDV T¢Glrglogies.
Polyt.ok is a badernadc of PdyLak, Irc. TUF--TNTE is a registered trademark of TUF-TM sea ultra Rn n a kadenlak of IPEX kuc
02013 kLlBatow VVMm Tedsw"ies. U jM All nghts reserved. RiWed n U.S.A 0250813
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
. OWNED CERTIFICATION FORM '
C ` 3
MaRing Address Lki' S~ (4
AM= Sr ProP~rtY i ~-~J
"(Veritf cation required from Planning & Zoning Department foir new camstractioa)
City/State 1 W Iyll \ t Parcel Identification Number 030 10 T5 - Sr ,3,0 Q
LEGAL DESCRIPTION
i
oP~Y LOcati ~ % , -Al 'la Sec. 3(? , T f~? N R 19 W, Town of
`st_ ScPtt
Subdivision Lot #
Certified Survey Map # i Li %U Volume 2-1 Page # SZ 1- Z
Warranty Deed # I b H q09 Volume Page
Spec house ye ) Lot Imes identifiable no
SYSTEM MAINTENANCE AND OWNER CERTMCATION
Iampropw use and maintenance of your septic system could result in its premature taihue to bundle wastes. Proper
maintenance consists of pumping out $e sepbc tank every three years or sooner if needed, by a licensed pumper. What you put into
the system can affect flue function of the septic tank as a treatment stage in the waste disposal system Owner Wince
respanstb Rf= are specified in §Comm_ 83.52(1) and to chapter 12 - St Croix Cowtty Sanitary Ordiwace-
The WoPerty owner agrees to submit to St. Croix County Planting & Z*nmg Department a ccctificaiion form, signed by the
owner and by_ trmaster Pte, l041=yman per, restricted pkmiber or a licensed pumper verifybtg that (1) the or-site
wastcwater-disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less thaw 1/3 full of sludge,
r
have read the above req,*~ne^+s ar-A agree to maiam the private seesaw disposal syst= with the
standards sett;-bein, as setby the Deparm i of Comunne = and the Dot of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been ,„a;.w Rued must be compleftd and -tm=d to the St Crone Cou W Planizing &
Z4DAg Departmentwitbin 30 days of the three year eViration date.
a' We certify that all
star this foam are true to the best of my/our knowtedge, vwe am/are the owner(s) of the
`j properip desexibed above, b e of a
dwTiccorded at Re '
gistcr of Deeds Office.
er of Pedrooins
SEP 14/ 2817
STGNATUR OF APPLICANT(S) DATE
***Any information that is mid may result in the saattny prsmrt being revoked by the Plan=g & Zeaing Departmcm2
lilk a with this application a recorded warranty deed from the Rqpster of Deeds Office and a copy of Sue certified survey map if
referaoce is made in the WILM833Ry deed.
(REV 08/05)
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