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AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS T /
SUBDIVISION / CSM#
SECTION LT #
- _T-:Z,LN_R__& W1 Town of
ST. CROIX COUNTY, WISCONSIN
PLAN I
SHOW EVERYTHING WITHIN
100 FEET OF SYSTEM
tea'
.7s'
Provide setback and elevation information on revers
Provide e of this form.
2 dimensions to center Of septic tank manhole cover.
t
BENCHMARK:
d~1p a
ALTERNATE BM:
2~
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Lj~'fzS Liquid Capacity:
Setback from: WellHouse Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 7S` Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer & ST Inlet: k42 ST outlet: S,rQ
PC inlet PC bottom Pump Off
Header/Manifold 9ZS:2 Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: -C'
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety'and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxPSWTe 2.:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)).
Town o : State Plan ID No.:
e: Haga
gni2 Kntdais.~la ,
GARY ~bt~RgET j
CST BM E'Iev :1V~\1{ Insp. BM Elev.: BM~scription: L'' Parcel ~x3f_:1045-20-000
}j
c G
TANK INFORMATION ELEVATION DATA A9700185
TYPE MANUFACTURER CAPACITY STATION BS HI ELEV.
Septic Benchmark
Dosing
Aerati Bldg. Sewer y3 /
Holding St/ij( Inlet
TANK SETBACK INFORMATION St/ FX Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic Z 4 NA Dt Bottom"
Dosing NA Header..- q p~ ' j< cg
Aeration NA Dist. Pipe
olding Bot. System 9"" 4v,
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model umber GPM
TDH Lift Fr' ion System TDH Ft
Forcemain ength Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length i No. Of T enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS s DIMENSIONS—
nufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHIN
INFORMATION Type O C ER Moe Number:
System: C6,v L o-J Qi) ✓ R UNIT
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length _La Dia. Length Z Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst
Depth Over Depth Over xx Depth Of x Seeded/Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)) U- RE F= -
LOCATION: SOMERSET 16.31.19.225,SW,NE 2152 CTY RD I LOT 1
_J
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building water systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit u ber rfi
;718g3108
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)). ~I ('i ~yGiy~~ State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prop y Owner Name Property Location
~tv,/4 1/4, S T , N, R E (or)O
Property qlkne;'s Math Addr s Lot Number Block Numb
S
Ci tate Zip Code Phone Number Subdivision Name or CSM Number
( ) -
II. TYPE F BUILDING: (check one) ❑ State Owned It~l Nearest clad
p VIIIage
❑ Public 1 or2 Family Dwelling - No. of bedrooms Town OF c,
111. BUILDING USE: (If building type is public, check all that apply) Parcel T x Number s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. IM New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Ea Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min h ch) Elevation
5~;IS-;7 1 ~7 IV~ Feet Feet
Z/~~, ]
VII. TANK Caa
in gallons it Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Exist in structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ - ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the, ndersigne , assume responsibility for in allation of the onsite sewage system shown on the attached plans.
Plum er' ame (Pr Plum "SS n tur ps) MP/MPRSW No.: Business Phone Number:
Plu tier's Address Cit , State, Z)ode):
Wry
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given initial a Surcharge Fee)
Adverse Determination d o
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divi ion, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings ,Division, 608-266-3815-
To be complete and accurate this'sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use, If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information- Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g_ MP, etc.),
address and phone number. Plumber must sign application form. .
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Commerce 'SO ILA ",S EVALUATION Page ~ of
Division of Safety And Buildings
Bureau of Integrated Services in AccorddWtith s. 83.09, Wis. Adm. Code
cr> N County
Attach complete site plan on paper not less thin 6 1/2 x 11 inches sifllan ust
include, but not limited to: vertical and horizontal refere m_ ) b ion d
percent slope, scale or dimensions, north arrod loc tibn i e to ne roe road. Parcel I.D. #
APPLICANT INFORMATION - Please p 't irmatio - Reviewed by Date
Personal information you provide may be used for secondary p e n (1) (m)).
Pro a Owner Property Location
vt. Lot 5~ 1/4. 1/4,S T N,R F'(oo
Go
2C
Property rs Mailing Address Lot # Block# Subd. Name or CSM#
i State Zip Code Phone Number ❑ Ci ❑ Village Town Nearest Road
New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 5 gpd Recommended design loading rate bed, gpd/ft2 1 6? trench, gpd/ft2
Absorption area required bed, ft2 SZL2 ' ttrre-nnch, ft2 Maximum design loading rate bed, gpd/ft2___,T_trench, gpdht2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material mss, Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system [Z S ❑ U Ws ❑ u as ❑ u as ❑ u ❑ s ®u ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont for Gr. Sz. Sh. Bed , Trench
m.
Ground _ S -
ev. ft
Depth to
limiting
factor. ,
Remarks:
Boring # ~
v
_ s c
Ground
eley.
Depth to
limiting
fact
In. Remar s: f
CST Name V(Plse rint) Signature Telephone No.
Address Date CST Number
y
PROPERTY OWNER -Jc' ~v SOIL DESCRIPTION REPORT
4eq Page ~ t*
PARCEL I.D.ff
Boring # Horizon Depth Dominant Color Mottles Stnmture
in. Munsell Qu. Sz. t. Color Texture Gr. Sz Sh.~ Roots
Bed , Trench
Ground _
4
Depth to
limiting
factor
i?~~1Lin• ,
Remarks:
Boring #
p
Ag,
Ground
elev.
Depth to
limiting
fact
of
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PDV
in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench
Boring #
z e
i
Ground
elev.
Depth to
limiting
factor
?,LDL-in' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
~n' Remarks:
SBD-8330 (R. 07/96)
a
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CERTIFIED SURVEY MAP
LOCATED IN THE SW 1/4 OF THE NE 1 /4 OF SECTION 16, T31 N,
R 19W, TOWN OF SOMERSET, ST. CROIX COUNTY, WISCONSIN.
LEGEND D m 0 N
COUNTY SECTION CORNER, cn z K
MONUMENT, BERNTSEN CAP, m
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NE CORNER
SECTION 16
UNPLATTED LANDS T31N, R19W
N
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V
S 89008'31" E rn m
468.00' I Z
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102 r cn
I D M ROADWAY EASEMENT TO BE N
I~ CREATED BY SEPARATE DOCUMENT
I N POINT OF -'w
BEGINNING
LA
N 89008' 31 " W w
468.00'
N 89°08' 31" W
1942.74'
UNPLATTED LANDS
N
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OWNER & SUBDIVIDER
WILMA SCHACHTNER C' i 1A rnDKIC0
Z 30 Z 39Vd
S10I IVNO11IOOV 3H1
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1,1 - I I ' ^.I I kILI I »n in 1 LI I n A -11 1 1 n 1 a. 1 • 7.6C 1 AA I C` Oft - LZO AI
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Ownerof property (I-xy., SC'A4C Z*"7 C
Location of propertyS 1/4 JV 1 1/4, Section , Tj/ N-R19 W
S`d~h ,Sf
Township /Sno ee ell- Mailing address ;V0,0
S6ty~E',~SE' t 44 ~7 6a~S~
Address of site
Subdivision name Lot no.
Other homes on property? Yes_ No
Previous owner of property ~N I m A Gh~mot
Total size of property 3. 008' A
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes XNo
Volume ja and Page Number 3,;2 ;7S as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. S- 0.S 34 , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signs ure of Applicant Co-Applicant
6-s-%7
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER G AK X Sc AA C W n f9
MAILING ADDRESS o~ c; O 570 5-
PROPERTY ADDRESS
(I cation of septic stem) Please obtain from the Planning Dept.
CITY/STATE 5,0y2PQ }-e
PROPERTY LOCATION S 1/4, K/ C_ 1/4, Section ZA6 T --3j N-R
'OWN OF .So~i7P~ SC' ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME PAGE 3~ ?s,LOT NUMBER_
_
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: S
DATE: 6 " -5 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
- , r
VOL 1145PAI.E09f
e '
560807 STATE BAR OF WISCONSIN FORM 3 - 1982
QUIT CLAIM DEED
DOCUMENT NO.
Wilma M. Schachtner, individually and as general ST. CROIX CO., WI
partner of the Schachtner Family Limited Partnership FwcdtorRacorn
quit-claims to Gary D. Schachtner JUN 10 1997
AM
Aegistiar of Doe&
the following described real estate in St. Croix County,
State of Wisconsin:
THIS SPACE RESERVED FOR RECORDING DATA
Part of the SW 1/4 of the NE 1/4, Section 16, Township NAME AND RETURN ADDRESS
31 North, Range 19 West, described as Lot 1 of G n V- p S c ~q c `t ~ti e'v-
Certified Survey Map filed June 5, 1997 in Volume 12, Y
Y P o o , 4) 4-k S -k,
page 3275, as Document No. 560536. 2 2
50 -e *r LL) T_ .5
Part of 032-1045-30
PARCEL IDENTIFICATION NUMBER
# ►'EE
157
I'
This is not homestead property.
26§)i (is not)
Dated this day of u VN p , 19 97
(SEAL) (SEAL)
Wilma M. Schachtner
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
S. t ` C r vNl County.
.1-_r ,n De_......,,11- ,.,,„,e l.ef .e - 'I". a.,.. ,.r