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DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.16600015 <br /> ELEVATION FORM Expires February 28,2014 <br /> PAPERWORK BURDEN DISCLOSURE NOTICE <br /> Public reporting burden for this data collection is estimated to average 115 hours per response. The burden estimate includes the time for reviewing instructions. <br /> searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required toobturr 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 add 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(NF IP)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 Hara rd Area(SF HAI,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 hounds,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 In process your request,all information on this form must be completed in its entirety. Incomplete submissions will <br /> result in processing delays. <br /> 1. NEW Community Number: 550032 Property Name or Address: 27209 Jamison Road,Webster,WI 54893 <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) El Yes ®No <br /> If yes,what is the date of the current re leveling? I (month/year) <br /> 5. What is the elevation datum?11 NGVD 29 ® NAVD 88 ❑ Other(explain) <br /> It 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.,NGVO 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 ®NAD83 ❑ NAD27 Lat.45.90302° Long,-92.39147' <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. Long. <br /> Lowest <br /> Block Lowest Lot Adjacent Base Flood BEE Source <br /> Address Lot Number Number Elevation- Grade To Elevation <br /> Structure <br /> House 934 OT 933' FIRM _ <br /> 401 detached garage 933.11' 933' FIRM <br /> This certification is to be signed and sealed ma licensed land surveyor,registered professional engineer,or architect sumprized by law to certify elevation <br /> Information. All documents submitted in support of this request are correct to the best of my knowledge. 1 understand that any false statement maybe punishable <br /> by fine or imprisonment under Title 19 of the United Slates Code,Section ID01. _ <br /> Certifiefs Name: MarkE lconge license Ne.: PL541808 Expiration Nte. Ianuary31,2016 <br /> Company Name: Wagner Surveying Assoc.Inc. Telephone No.: 715-8664295 <br /> Email:wagnersurniong@centerytelmot Fax No,7158664206 <br /> Signature: Date: <br /> For requests involving a portion of property,include the lowest ground elevation within <br /> the metes and bounds description Seal(optional) <br /> Please oleo(the Lowest Adjacent Grade to Structure is the only elevation provided,a determination <br /> will be issued for the structure Falls. — <br /> OHS -FEMA Farm 086 0 26A,FEB 11 Elevation Form 617-1 porn)2 Page 1 of 2 <br />