Creek Wood Park_Timber-Hyrst Place No. 2Masterpiece on the Mississippi
Dubuque
All-ame acmr
11111
2007
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Acceptance of Deed and Recommendation of Park Name as Creek Wood
Park
DATE: September 1, 2011
Leisure Services Manager Marie Ware recommends City Council acceptance of the
donation by Marty McNamer of Lot 2 of Timber -Hyrst Place #2 subdivision for a mini
park. The Park and Recreation Commission recommends naming the park Creek
Wood Park as it is located on Creek Wood Drive. It is recommended that the City
Council select Creek Wood Park as the name for this park.
Currently no funds are budgeted for development of this park area. Marty McNamer
discussed the opportunity to find private donors and /or Leisure Services will budget in
this fall /winter Capital Improvement Program budget process.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
Mic ael C. Van Milligen
MCVM:jh
Attachment
cc: Barry Lindahl, City Attorney
Cindy Steinhauser, Assistant City Manager
Marie L. Ware, Leisure Services Manager
Prepared by Barry A. Lindahl, Esq. 300 Main Street Suite 330 Dubuque Iowa 52001 563 583 -4113
RESOLUTION NO. 309 -11
ACCEPTING THE DEED TO CERTAIN REAL ESTATE IN DUBUQUE COUNTY,
IOWA FROM NORTH CASCADE ROAD DEVELOPERS, LLC, AN IOWA
LIMITED LIABILITY COMPANY
WHEREAS, North Cascade Road Developers, LLC desires to make a gift
of the following described real property to the City of Dubuque:
Lot 2 of Timber -Hyrst Place #2 in the City of Dubuque, Iowa,
according to the recorded plat thereof, subject to easements and
restrictions of record
AND WHEREAS, the City Council of the City of Dubuque desires to
accept the gift on behalf of the City.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF DUBUQUE, IOWA, AS FOLLOWS:
1. The City of Dubuque hereby accepts the Warranty Deed from North
Cascade Road Developers, LLC, a copy of which is attached hereto.
2. The City Clerk is hereby authorized and directed to record this
Resolution and the Warranty Deed with the Dubuque County Recorder.
Passed, approved and adopted this 6th day of September , 2011.
Roy D. ol, Mayor
Attest:
C-
Kevin . Firnstah , Acting City Clerk
F:\ USERS \tsteckle \Lindahl \Timber -Hyrst Park\ ResolutionAcceptingDeed _081611.doc
o`5TA7A-
". (Corporate/Business iness Entity Grantor)
Warranty Deed
' THE IOWA STATE BAR ASSOCIATION
Official Form #335
SbCA18 0 Recorder's Cover Sheet
Preparer Information: (Name, address and phone number)
Barry A. Lindahl Suite 330, 300 Main Street, Dubuque, Iowa 52001 (563) 583 -4113
Taxpayer Information: (Name and complete address)
City of Dubuque 50 West 13th Street, Dubuque, Iowa 52001
Return Document To: (Name and complete address)
Barry A. Lindahl Suite 330, 300 Main Street, Dubuque, Iowa 52001 (563) 583 -4113
Grantors:
North Cascade Road Developers, LLC
Grantees:
City of Dubuque, Iowa, a municipal
corporation of the State of Iowa
Legal description: See Page 2
Document or instrument number of previously recorded documents:
0 The Iowa State EarAssociatian 2005
KOWADOCSO
THE IOWA STATE BAR ASSOCIATION
Official Form No. 935
Barry A. Li ndah 1
FOR THE LEGAL EFFECT OF THE USE OF
THIS FORM, CONSULT YOUR LAWYER
STATE,
a
et ..:0
valuable
le
'
For the consideration
consideration, North
Warranty Deed
(Corporate/Business Entity Grantor)
of one Dollar(s) and other
Cascade Road Developers, LLC
a(n) Iowa limited liability company organized
and existing under
Dubuque, Iowa, a
the laws
municipal
of Iowa does hereby Convey to City of
corporation of the State of Iowa
the
following described real estate in
#2 in the City of Dubuque, Iowa,
covenants with grantees, and successors
that it has good and lawful authority
clear of all liens and encumbrances,
Defend the real estate against the
herein, including acknowledgment
to the context.
\\
Dubuque County, Iowa:
Lot 2 of
estate
the real
covenants
may be
gular or
Dated:
STATE
by Martin
Timber -Hyrst Place
The grantor hereby
by title in fee simple;
estate is free and
to Warrant and
above stated.
Words and phrases
plural number, according
W\ 1(-‘
according to the recorded plats thereof
in interest, that it holds the real
to sell and convey the real estate; that
except as may be above stated; and it
lawful claims of all persons, except as
hereof, shall be construed as in the sin-
Road Developers, LLC ,
OF IOWA , COUNTY
North Cascade
a(n) low limile��j��li�y-eom pan
By_________2_______,
Martin J. McNamer , Manager
By
OF Dubuque
,,((,,
l` (iy )1
This instrument was acknowledged before me on this
J. McNamer
t' /
Mrt- J. )
as Manager
of North Cascade Road Developers, LLC .
..-- -AL -- , Alb, -_.An.
.
r,
I
I
I
JAMES 0 SNIPPY
Notarial seal - Iowa
Commission 0 75 5 4
My Commission Expires
0 0 , Notary Public
U
•
I
CThe Iowa Slate Bar Association 2005 336 WARRANTY DEED (CORPORATEIBUSINESS ENTITY DEED)
IOWAOOCSdv Revised June 2005
(Pay 1 of 3)
PREPARED BIT BUESNO ASSOQAIFS
11111111111111111111111111111
Doc ID: 00844012003 Type: GEN
Recorded: 04/28/2008 at PM
: $17.00 Pape 1 of 3
Dubuque County Iowa
Kathy Flynn Thurlow Recorder Q
F11a2O09- 00008128
ADDRESS 1212 LOCUST STREET, DUBUC% IOWA 200 PHONE (5031 538 -8318
Plat of Survey of:
TIMBER -HYRST PLACE #2
IN THE CITY OF DUBUQUE, IOWA.
Comprised of: LOT 1 OF TIMBER -HYRST ESTATES #2 IN THE NW1 /4 OF SECTION 2 AND LOT 13 OF TIMBER -HYRST
ESTATES IN THE NE1 /4 OF SECTION 2 BOTH IN THE CITY OF DUBUQUE IN T88N, R2E, (TABLE MOUND TWP.), OF THE
5111 P.M., DUBUQUE COUNTY, IOWA
LOT 50
TIMBER -NYRST
ESTATES #2
LOT 15
T1MBER -HYRST
ESTATES
LOT 47
TIMBER -HYRST
ESTATES #2
/
10' PUE
LOT 12
11MOER -HYRST
ESTATES
LOT 2
11MBER -HYRST 0
ESTATE /2- —
10'
20'
�Dw —
W
cR �K 60
10' PUE1, 174.0•
79'19'47°E
LOT
LOT 1 — -�
T1MBE$- .H0RSTAESTATES 12
26,266sf
▪ LOT- 2 - -
a
p�, 43,574sf
Ntl3 LOT 13
's. TIMBER -HYRST ESTATES
CP
59:
20' STORM
SEWER
EASEMENT
LOT 2 S 1/2, NW FRL
1/4 SEC 2, T88N, R2E
NOTE
LOT 1 OF TIMBER-HYRST ESTATES /2 IN
THE NW1 /4 OF SECTION 2 AND LOT 13 OF
TIMBER -HYRST ESTATES IN THE 901/4 CF
SECTION 2 80111 IN 188N, R2E. (TABLE
MOUND TAP.). OF 111E 519 PM.. DUBUQUE
COUNTY, 009
LEGEND
1-'
N ▪ 1V
v N
0 ,-
M
N
W
0
N
0
0 1n
Z m
ti
25.
LOT 30
TIMBER -HYRST
ESTATES
NO CAP
0 5/d RER00 (FOUND)
(CAPPED, '4016', YELLOIY)
• 1/2' RER03 (F0080)
(CAPPED, 1441r, YELLOW)
RER00 (FOUND)
• (CAPPED, '12631', RED)
(UNLESS SOTTO 01NERWSE)
5/e• RER00 (PLACED) (W/ YELLOW
P1A511C CAP MARKED 'AM 4018')
0
DOMINO PROPERTY UNE
— — — PJ134T OF WAY (ROW) UNE
— — -- — EASEMENT UNE
- - — FORMER PROPERTY UNE
( ) RECORD DIMENSION
ROW FOCHT OF WAY
PUE PUBLIC UTILITY EASEMENT
OWNER @ PROPMET011
LOT 1 IN 11MBER -HTRST ESTATES /2
AND LOT 13 IN TIMBER -HYRST ESTATES IS
NORTH CASCADE ROAD DEVELOPERS, LLC
'23.82' (23.74')
-•- 33.03' (33.11')
FOUND 1/2' YELLOW
14417 WITTNESS CORNER
O 39' NORTH OF
CENTER, SEC 2, 188N,
R2E
LOT E
TIMBER -NYRST
ESTATES
50' 100'
■TTDI•:•, ,a,r,� ��'7CEORD I F911,- i•.;.�1;1! :a /�d;�;i'e
EMI XIIMi>TMIL ET Fr,-.S2/1- Z�ti1■11E—i1422i iEr Eli
:Nil}
1. ALL MEASUREMENTS ARE IN FEET AND DECIMALS THEREOF.
(711111111111/ // 1 HEREBY CERTIFY THAT THIS LAND SURVEYING DOCUMENT WAS
P AREA AND 111E RELATED SURVEY WORK WAS PERFORUED BY ME OR
(N MY DIRECT PERSONAL SUPERVISION AND THAT 1 AM A DULY
ii>j� UNDERDE ; Jt0E4 STATE OF IOWA.
-EE` J M JOHN LY E • O E
V* / / R (I IOI I 1 I A \ \ \ \ \Y \S
N L. I
CENSE NUMBER 4018
MY LICENSE RENEWAL DATE IS DECEMBER 31, 2010
SHEETS COVERED BY THIS SEAL : SHEETS 1 k 2
SHEET 1111E
PROJECT I N0. 07085
PLAT OF SURVEY
PREPARED 0-08
NORTH 0ASCAOE ROAD HNVELOP07, LLC
R MARIS MWAMER
5070 5220002
la %DIM G
808201RB Aem BNRFg01@
aH IM1n. Ka•I8&w
aJFatE
DATE
4/23/09
SCALE:
RE1SIONS
DRAM BY:
NM.
CHECKED BY:
- 200'
.0.W
/7-
Book , Paae , File Number 2009 - 00008128
Masterpiece on the Mississippi
TO: Michael C. Van Milligen, City Manager
FROM: Marie L. Ware, Leisure Services Manager j
to)
SUBJECT: Acceptance of Deed and Recommendation of Park Name
as Creek Wood Park
DATE: August 26, 2011
INTRODUCTION
Dubuque
AN- Americacily
11111!
2007
The purpose of this memorandum is to accept the donation of Lot 2 of Timber -Hyrst
Place #2 subdivision for a mini park and recommend name for park.
BACKGROUND
Marty McNamer wishes to donate Lot 2 in Final Plat which is 43.574 sq. ft. (one acre).
The area closest to Creek Wood Drive has been graded with a flat area that can support
a playground with benches and a water fountain. The remainder of the proposed area is
a south facing slope that is forested and an open space hillside. It is a scenic hilltop
location that in the fall catches glimpses of Catfish Creek.
The proposed park would primarily service this subdivision and neighboring residential
areas. The closest mini park in the area is Marna Ridge Children's Forest. Valentine
Park serves as a neighborhood park to the area.
Currently no funds are budgeted for development of this park area. Marty McNamer
discussed the opportunity to find private donors and /or Leisure Services will budget in
this fall /winter C.I.P. budget process. The development of this park would have the play
equipment on the flat area near Creek Wood Drive on the east side of the lot.
Sidewalks will need to be installed. This part of the park will be manicured. The hillside
would be native area and the forested area is already established.
The Parks and Recreation Commission reviewed the donation request and recommend
City Council approval. City Attorney, Barry Lindahl has completed a title opinion
warranty and a resolution accepting the deed. The Park and Recreation Commission
recommended naming the park Creek Wood Park as it is located on Creek Wood Drive.
I concur with this recommendation.
continued
RECOMMENDATION
I recommend accepting the deed and naming the park Creek Wood Park.
MLW:et
enclosures: Resolution
Warranty Deed
General development plan for park
Photos of proposed park area
cc: Laura Carstens, Planning
Barry Lindahl, Legal
Native Planting`Area
Warranty Deed
(Corporate/Business Entity Grantor)
THE IOWA STATE BAR ASSOCIATION
Official Form #335
Recorder's Cover Sheet
111111111111111111111111111111111
Doc ID: 007191920005 Type: GEN
Recorded: 1 WITH 01 /20111 at 04:00:18 PM
Fee Amt: $32.00 Page 1 of '5
Revenue Tax: $0.00
Kathy uFlynn nThurlow Recorder
File 2011_00016334
Preparer Information: (Name, address and phone number)
Barry A. Lindahl Suite 330, 300 Main Street, Dubuque, Iowa 52001 (563) 583 -4113
Taxpayer Information: (Name and complete address)
City of Dubuque 50 West 13th Street, Dubuque, Iowa 52001
Return Document To: (Name and complete address)
Barry A. Lindahl Suite 330, 300 Main Street, Dubuque, Iowa 52001 (563) 583 -4113
Grantors:
North Cascade Road Developers, LLC
Grantees:
City of Dubuque, Iowa, a municipal
corporation of the State of Iowa
Legal description: See Page 2
Document or instrument number of previously recorded documents:
®The Iowa State BarAssociation 2005
10WAOOCS®
THE IOWA STATE BAR ASSOCIATION
Official Form No,. 336
Barry A. Lindahl
FOR THE LEGAL EFFECT OF THE USE OF
THIS FORM, CONSULT YOUR LAWYER
2 ‘
�ssocinctc)
For the consideration
valuable consideration, North
Warranty Deed
(Corporate/Business Entity Grantor)
of one Dollar(s) and other
Cascade Road Developers, LLC
a(n) Iowa limited liability company organized
and existing under
of Dubuque, Iowa, a
the laws of Iowa does hereby Convey to City
municipal corporation of the State of Iowa
the following described real estate in Dubuque County, Iowa:
Lot 2 of Timber -Hyrst Place #2 in the City of Dubuque, Iowa, according to
The grantor hereby covenants with grantees, and successors in interest,
estate by title in fee simple; that it has good and lawful authority to sell and
the real estate is free and clear of all liens and encumbrances, except as may
covenants to Warrant and Defend the real estate against the lawful claims
may be above stated.
Words and phrases herein, including acknowledgment hereof, shall
gular or plural num er, according to the context.
Dated: ? 1 L\ 11
the recorded plats thereof
that it holds the real
convey the real estate; that
be above stated; and it
of all persons, except as
be construed as in the sin-
LLC ,
STATE OF IOWA
North Cascade Road Developers,
a(n) .. . le •s_..Jima, .• Zany
�
-----
By
Martin J. McNamer , Manager
By
, COUNTY OF Dubuque
,(� ,,11�,� qq,,��
( 4)(903']a, ex) / ,
This instrument was
by Martin J. McNamer
//�
acknowledged before me on this /ra ))
as Manager
of North Cascade Road Developers, LLC
1
, t,.
JAMES 0
Notarial seal
Commission
My Commission Expires
—.••/.1 — • -iL
BHIPPY I 4 , Notary Public
- Iowa
5 4 I
W 75 31 /ii
p'
®The Iowa Slate Bar Assodalion 2005 336 WARRANTY DEED (CORPORATEIBUSINESS ENTITY DEED)
IOWADOCS® Revised June 2005
Prepared by Barry A. Lindahl, Esq. 300 Main Street Suite 330 Dubuque Iowa 52001 563 583 -4113
RESOLUTION NO.30.9 -11
ACCEPTING THE DEED TO CERTAIN REAL ESTATE IN DUBUQUE COUNTY,
IOWA FROM NORTH CASCADE ROAD DEVELOPERS, LLC, AN IOWA
LIMITED LIABILITY COMPANY
WHEREAS, North Cascade Road Developers, LLC desires to make a gift
of the following described real property to the City of Dubuque:
Lot 2 of Timber -Hyrst Place #2 in the City of Dubuque, Iowa,
according to the recorded plat thereof, subject to easements and
restrictions of record
AND WHEREAS, the City Council of the City of Dubuque desires to
accept the gift on behalf of the City.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF DUBUQUE, IOWA, AS FOLLOWS:
1. The City of Dubuque hereby accepts the Warranty Deed from North
Cascade Road Developers, LLC, a copy of which is attached hereto.
2. The City Clerk is hereby authorized and directed to record this
Resolution and the Warranty Deed with the Dubuque County Recorder.
Passed, approved and adopted this 6th day of September , 2011.
Attest:
Kevin Firnstah , Acting City Clerk
F: \USERS\tsteckle \Lindahl \Timber -Hyrst Park\ ResolutionAcceptingDeed _081611.doc
CERTIFICATE of the CITY CLERK
STATE OF IOWA
) SS:
COUNTY OF DUBUQUE
I, Kevin S. Firnstahl, do hereby certify that I am the duly appointed, qualified, City Clerk
of the City of Dubuque, Iowa, in the County aforesaid, and as such City Clerk I have in
my possession or have access to the records of the proceedings of the City Council. I
do further state that the hereto attached Resolution No. 309 -11 is a correct copy of the
original Resolution No. 309 -11 approved and adopted by the City Council of the City of
Dubuque, Iowa, at a session held by said Council on the 6th day of September, 2011.
In Testimony Whereof, I hereunto set my hand and official seal of the City of Dubuque,
Iowa.
Dated at Dubuque, Iowa, on this 9th day of September, 20 1.
d
Kevin S. Firnstahl
City Clerk
Doc ID 007191940002 Type GEN
Kind: AMEND TO RESTRICT COVENANTS
Recorded: 11/01/2011 at 04 :03:28 PM
Fee Amt: $12.00 Pape 1 of 2
Dubuque County Iowa
Kathy Flynn Thurlow Recorder
File2011 -0001 6335
Prepared By and Return To: D. Flint Drake, 1005 Main Street, Suite 200, Dubuque, IA 52001 (563) 582 -2000
VARIANCE REGARDING DECLARATORY STATEMENT IMPOSING RESTRICTIVE
COVENANTS
RECITALS
A. North Cascade Road Developers, LLC (the "Developer ") filed a Declaratory Statement
Imposing Restrictive Covenants on May 14, 2008 as Instrument #2008 - 00006730 in the records of the
Dubuque County Recorder (the "Covenants ") with respect to the following described real estate:
Lots 1, 2, 4 and 6 -49 of Timber -Hyrst Estates No. 2 in the City of Dubuque, Iowa (the "Real
Estate ");
B. Paragraph one of the Covenants requires that all lots within the Real Estate be used solely
and exclusively for private single family residences and private garages. That paragraph also provides
that the Developer may "...grant a variance to allow any use permitted within the R -3 zoning designation
within the zoning ordinance of the City of Dubuque, Iowa..." (a "Variance ");
C. Developer has agreed to convey Lot 2 of Timber Hyrst- Estates No. 2 to the City of
Dubuque, Iowa for development by the City of a public park/recreation area;
D. The current zoning ordinances of the City of Dubuque, Iowa allow development of
"public parks, recreation areas, playgrounds and community centers..." within an R -3 Single Family
Residential District (see Ordinance 1- 15.5(a)(7), 2011);
E. The Developer desires to grant a Variance with respect to Lot 2 of Timber -Hyrst Estates
No. 2 in the City of Dubuque, Iowa for development of a public park and recreation area upon such lot
and desires to set forth such Variance in writing.
THEREFORE, the Developer states as follows:
1. Grant of Variance. The Developer hereby grants a Variance to the restrictions imposed
by the Covenants with respect to Lot 2 of Timber -Hyrst Estates No. 2 in the City of
Dubuque, Iowa and expressly states that a public park and /or recreational area may be
developed upon such lot by the City of Dubuque, Iowa.
CRj C�er la°`)
2. Effect on Covenants. Except as modified by the Variance granted herein, the Covenants
shall continue to govern the rights and obligations of owners of the lots affected thereby.
NORTH CASCADE ROAD DEVELOPERS,
LLC
By:
STATE OF IOWA
COUNTY OF DUBUQUE ) ss:
artin J. McNamer, Managing Member
On this 8 day of (S , 2011, before me, a Notary Public in and for the State
of Iowa, personally appeared Martin J. Mc amer, to me personally known, who being by me duly sworn
did say that he is the Managing Member of said limited liability company, that (the seal affixed hereto is
the seal of said)(no seal has been procured by the said) limited liability company and that said instrument
was signed (and sealed) on behalf of said limited liability company by authority of its managers and the
said Martin J. McNamer acknowledged the execution of said instrument to be the voluntary act and deed
of said limited liability company, by it voluntarily executed.
AMES 0 SNIPPY
NottdSi Nth 75556
Comntooion - �,,t"r
My ComMISSion IOW
41
Public in and for the State of Iowa
1 lii1ii1111iI iii ii111 ii1111iii11 1 11111111111111111111 iii ii111 ii11i 111111
Doc ID 007191930002 Type GWH
Kind GROUNDWATER HAZARD
Recorded: 11/01/2011 at 04:00:32 PM
Fee Amt: $0.00 Page 1 of 2
Dubuque County Iowa
Kathy Flynn Thurlow Recorder
F11e2011- 00001656
REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT
TO BE COMPLETED BY TRANSFEROR
TRANSFEROR:
Name North Cascade Road Developers, LLC
Address 5070 Wolff Road Dubuque Iowa 52002 -2561
Number and Street or RR City, Town or P.O. State Zip
TRANSFEREE:
Name City of Dubuque, Iowa
Address 50 West 13th Street Dubuque Iowa 52001
Number and Street or RR City, town or N.O.
State Lip
Address of Property Transferred:
1798 Creek Wood Dr., Dubuque, Iowa 52003
Number and Street or RR City, Town, or P.O. State Lip
Legal Description of Property: (Attach if necessary) Lot 2 of Tunber -Hyrst Place # 2 in the City of
Dubuque, Iowa, according to the recorded plats thereof
1. Wells (check one)
A[ There are no known wells situated on this property.
There is a well or wells situated on this property. The type(s), location(s) and legal status are
stated below or set forth on an attached separate sheet, as necessary.
2. Solid Waste Disposal (check one)
there is no known solid waste disposal site on this property.
— There is a solid waste disposal site on this property and information related thereto is provided
in Attachment #1, attached to this document.
3. Haz rdous Wastes (check one)
There is no known hazardous waste on this property.
— There is hazardous waste on this property and information related thereto is provided in
Attachment #1, attached to this document.
4. Underground Storage Tanks (check one)
1Z There are no known underground storage tanks on this property. (Note exclusions such as
small farm and residential motor fuel tanks, most heating oil tanks, cisterns and septic tanks, in
instructions.)
There is an underground storage tank on this property. The type(s), size(s) and any known
substance(s) contained are listed below or on an attached separate sheet, as necessary.
FILE WITH RECORDER DNR form 542 -0960 (Sept. 1, 2010)
�l1-
WY/
5. Priv to Burial Site (check one)
There are no known private burial sites on this property.
_ There is a private burial site on this property. The location(s) of the site(s) and known
identifying information of the decedent(s) is stated below or on an attached separate sheet, as
necessary.
6. Private Sewage Disposal System (check one)
TIl buildings on this property are served by a public or semi - public sewage disposal system.
his transaction does not involve the transfer of any building.
There is a building served by private sewage disposal system on this property or a building
without any lawful sewage disposal system. A certified inspector's report is attached which
documents the condition of the private sewage disposal system and whether any modifications
are required to conform to standards adopted by the Department of Natural Resources. A
certified inspection report must be accompanied by this form when recording.
There is a building served by private sewage disposal system on this property. Weather or
other temporary physical conditions prevent the certified inspection of the private sewage
disposal system from being conducted. The buyer has executed a binding acknowledgment
with the county board of health to conduct a certified inspection of the private sewage disposal
system at the earliest practicable time and to be responsible for any required modifications to
the private sewage disposal system as identified by the certified inspection. A copy of the
binding acknowledgment is attached to this form.
_ There is a building served by private sewage disposal system on this property. The buyer has
executed a binding acknowledgment with the county board of health to install a new private
sewage disposal system on this property within an agreed upon time period. A copy of the
binding acknowledgment is provided with this form.
_ There is a building served by private sewage disposal system on this property. The building to
which the sewage disposal system is connected will be demolished without being occupied. The
buyer has executed a binding acknowledgment with the county board of health to demolish the
building within an agreed upon time period. A copy of the binding acknowledgment is provided
with this form. [Exemption #9]
_ This property is exempt from the private sewage disposal inspection requirements pursuant to
the following exemption [Note: for exemption #9 use prior check box]:
The private sewage disposal system has been installed within the past two years pursuant to
permit number
Information required by statements checked above should be provided here or on separate
sheets attached hereto:
Signature:
I HEREBY DECLARE THAT I HAVE REVIEWED THE INSTRUCTIONS FOR THIS
FORM
AND THAT THE INFORMATION STATED ABOVE IS TRUE AND CORRECT.
FILE WITH RECORDER
Telephone No.: (563 )
DNR form 542 -0960 (Sept. 1, 2010)