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DEPARTMENT OF FROM ELAN D SECURITY-FEDERAL EM ERG ENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 <br /> ELEVATION FORM I <br /> Expires February 28,2014 <br /> PAPERWORK BURDEN DISCLOSURE NOTICE <br /> Public reporting burden for this data collection Is estimated to average 125 hours per response. The burden estimate Includes the time for reviewing iratrui <br /> arching existing data sources,gathering and maintaining the needed data,and completing and submitting the form- This collection is required to obtain or retain <br /> benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the <br /> accuracy of the burden estimate and any suggestions for reducing this burden lo:Information Collections Management,Department of Homeland Security,Federal <br /> Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). at Oo not send your completed <br /> form to this address. <br /> This farm must be completed for requests and must be completed and signed by a registered professional engineer or Ilcensed land surveyor. A pHs-FEMA National <br /> Flood Insurance Program(ki Elevation Certificate may be submitted in lieu of this form for single structure requests. <br /> For rise nests to remove a structure on natural grade OR on engineered fi 11 from the Special Flood Hata rd Area SFHAhsubmit the lowest adjacent grade(the lowed <br /> ground touching the structure),including an attached deck or garage.For requests to remove an entire parcel of land from the SHIA,provide the lowest lot elevation, <br /> r,If the request involves an area described by metes antl bounds,provide the lowest elevation within the metes and bounds description.All measurements are to be <br /> ended to nearest tenth of a fool In order to process your request,all Information on this form must be completed in Its entirely. Incomplete submissions will <br /> result in processing delays. <br /> 1. NFIP Community Number: Property Name or Address: <br /> 2. Are the elevations listed below based on ©existing or ❑proposed conditions? (Check one( <br /> 3. For the existing or proposed structures listed below,what are the types of constructlon? (check all that apply( <br /> ❑crawl space X]slab on grade ❑basement/enclosure ❑other(explain) <br /> 4. Has DHS-FEMA identified this area as subject to land subsidence or uplift?(see instructions( 1-1 yes F1 No <br /> If yes,what Is the date of the current re-leveling? I (month/year) <br /> 5. What R the elevation datum)❑ NGVD 29 ONAVO 88 ❑ other(Explain) <br /> If any of the elevations listed below were computed using a datum different than the datum used for the effective Flood Insurance Rate Map <br /> (FIRM)(e.g.,NGVD 29 or NAVD 88),what was the conversion factor? <br /> Local Elevation+/-ft,=FIRM Datum <br /> 6. Please provide the Latitude and Longitude of the most upstream edge of the structure(in decimal degrees to the nearest fifth decimal place): <br /> Indicate Datum: ❑WG584 X❑ NAD83 ❑NAD27 Lot, 4592801 Long. -9237393 <br /> Please provide the Latitude and Longitude of the most upstream edge of the property(In decimal degrees to the nearest fifth decimal place): <br /> Indicate Datum: ❑WG584 ❑NAD83 ❑ NAD27 Lot Long. <br /> rawest <br /> Block Lowest Lot Adjacent Base Flood FIE Source <br /> Address Lot Number Number Elevation' Grade To Elevation <br /> Structure <br /> 27953 Lone Pine Road CSNA V.2. p.1 13 934.7 932.8 Yellow Lake <br /> This certification Is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation <br /> information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable <br /> by fine or imprisonment under Title 18 of the United State,Code,Section 1001. <br /> certifiers Name: Douglas R. Crane License No PIES#1511 WI Expiration Date: Jan. 31,2016 <br /> Company Name: North Country Surveying, Inc. Telephone No.: (715)349-5957 sssfeweillllrlli°pllr <br /> xo ,VSC(7iASj� ri <br /> Email: doug@ncs-wi com Fax No. (715)3497518 <br /> Signature: Date: Dec. 10, 2014 1 DDUGLA5 R. �c <br /> CRANE <br /> i = S-1511 <br /> �1. � L, �r t - g SIREN <br /> W6G .4- <br /> 'For requests involving a pacer of property,Include the lowest ground elevation withinr !-tthe <br /> bounds <br /> metes <br /> ,IIfIfMeLowestsAdjcent Grade to Structure is the only elevation provided,a determination rr9p/"It.....j, [s <br /> Pleaenote <br /> will be Issued for the structure only. <br /> DHS-FEMA Form 086-0-26A,FEB 11 Elevation Form MT-1 Form 2 Page 1 of 2 <br />