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DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 <br /> ELEVATION FORM Expires February 28,2014 <br /> PAPERWORK BURDEN DISCLOSURE NOTICE <br /> Faccuracy <br /> burden for this data collection is estimated to average 1.25 hours per response. The burden estimate includes the time for reviewing instructions, <br /> g data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain <br /> e 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 /> burden estimate and any suggestions for reducing this burden to: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). NOTE:Do not send your completed <br /> form to this address. <br /> This form must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS-FEMA National <br /> Flood Insurance Program(NFIP)Elevation Certificate may be submitted in lieu of this form for single structure requests. <br /> For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area(SFHA),submit the lowest adjacent grade(the lowest <br /> ground touching the structure),including an attached deck or garage.For requests to remove an entire parcel of land from the SFHA,provide the lowest lot elevation; <br /> or,if the request involves an area described by metes and bounds,provide the lowest elevation within the metes and bounds description.All measurements are to be <br /> rounded to nearest tenth of a foot. In order to process your request,all information on this form must be completed in its entirety. Incomplete submissions will <br /> result in processing delays. <br /> 1. NFIP Community Number: Property Name or Address: 24812 SUNFISH BAY RD, Siren,WI 54872 <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 construction? (check all that apply) <br /> ❑crawl space❑slab on grade ❑basement/enclosure ❑other(explain) <br /> 4. Has DHS-FEMA identified this area as subject to land subsidence or uplift?(see instructions) ❑Yes ❑No <br /> If yes,what is the date of the current re-leveling? / (month/year) <br /> 5. What is the elevation datum?❑ NGVD 29 ❑NAVD 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: ❑WGS84 ❑ NAD83 ❑ NAD27 Lat. 45,81692 Long. -92.3287`- <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: ❑WGS84 ❑NAD83 ❑NAD27 Lat. 45.81687 Long. <br /> Lowest <br /> Address Lot Number Block Lowest Lot Adjacent Base Flood BFE Source <br /> Number Elevation* Grade To Elevation <br /> Structure <br /> '14812 SUNFISH BAY RD Unit 3, Pond rosa Resort Co do q5a n 956.0 ,lam 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 States Code,Section 1001. <br /> Certifier's Name: Douglas R. Crane License No.: WI 1511-8 Expiration Date: 01/31/2026 <br /> Company Name:'lorth Country Surveying, Inc Telephone No.:(715)349-5957 <br /> Email: loug@ncs-wi.com Fax No. <br /> �tt0"turtrirril till <br /> „��ii <br /> signature: \ Date: 05/28/2025 <br /> _ 'RANI <br /> _ }(, S°REN _ <br /> *For requests involving a portion of property,include the lowest ground elevation within <br /> the metes and bounds description. <br /> Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a determination <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 />