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Parcel #: 032-1005-30-400 05/11/2006 03:44 PM
PAGE 1 OF 1
Alt. Parcel M 02.31.19.27E 032-TOWN OF SOMERSET
Current X! ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O-SCHERZ, JEFFREY
JEFFREY SCHERZ C-ZURCHER JANELL
ZURCHER JANELL
626 230TH ST
SOMERSET WI 54025
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *626 230TH AVE
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE
SEC 2 T31 N R1 9W SW SW LOT 4 OF C.S.M. Block/Condo Bldg:
6/1607
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
02-31N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
09/04/2003 738805 2400/138 WD
08/31/2001 655500 1711/520 LC
05/16/2001 645710 1640/628 QC
07/23/1997 1197/543 WD
more
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/22/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 58,000 124,000 182,000 NO
Totals for 2006:
General Property 5.000 58,000 124,000 182,000
Woodland 0.000 0 0
Totals for 2005:
General Property 5.000 58,000 124,000 182,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 118
Specials:
User Special Code Category Amount
I
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 600
PUMP CHAMBER
Manufacturer: quid Capacity:
Pump Model: Pump/ phon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elev ion: Gallons per cycle:
Alarm Manufactu r: Alarm Switch Type:
Number of f et from nearest property line: Front, O Side, O Rear, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan) .
SOIL ABSORPTION SYSTEM /
Bed: Trench: i/
20 Width: `
Length: Number of Lines: 2_ Area Built: 5cx3
,.
Fill depth to top of pipe: U
Number of feet from nearest property line: Front, n Side, O Rear,�I�t . �
Number of feet from well: }✓
Number of feet from building: T
(Include distances on plot plan) .
SEEPAGE PIT
Size: Num p& of pits: Diameter:
Liquid depth: / Bottom of seepage pit elevation:
Area Built:
Has either a droy'box O or distribution box O been used on any of the above soil
absorbtion syG,ems? (Check one).
HOLDING TALK
F
Manufacturer: Capacity:
i
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet frogp'nearest property line: Front, O Side, O Rear, O Ft.
414
/Number of feet from well:
Dumber of feet from building:
Numb/r of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: �'" �� _ g;:;' Plumber on job
License Number: 42 � Lj
3/84:mj
L
i
Form - STC - 104
.+ AS BUILT SANITARY SYSTEM REPORT
L -
OWNER r� - C-v,t"S-f TOWNSHIP SEC. T 3 N R �7 W
ADDRESS % ST. CROIX COUNTY, WISCONSIN
SUBDIVISION �e� ,,;��4 LOT LOT SIZE � �✓ �
PLAN VIEW
Distances and dimensions to meet requirements of IIHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
;-
-70.
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used � c�- F�( Q
Elevation of vertical reference point: � ��} ` Proposed slope at site: 1
SEPTIC TANK: Manufacturer: Liquid Capacity: 1cg-jo C I
Number of rings used: Tank manhole cover elevation: �8
Tank Inlet Elevation: o J 3 Tank Outlet Elevation: I
Number of feet from nearest Road:
Front,(n Side 10 Rear, 0 31131
1 13 feet
From nearest property line FrontSide,w Rear,O � feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MAQISON WI 53707
SW4,SWk,S2,T31N—R19W CONVENTIONAL El ALTERNATIVE State Plan l.D.Number:
• (If f S'omerse t f assigned)
o
Holding Tank ❑ In-Ground Pressure ❑Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: J
Bryon Forrest 630 Park Avenue, New Richmond, WI 54017 /1-r30 V_I?
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV..
Name of Plumber: MP/MPRSW No.: C.—Y, Sanitary Permit Number:
lGary L. Steel 13254 1 St. Croix 95999
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: AR ING LABEL LOCKING COVER
i P IDED: PROVIDED:
I� Q 2 I YES ❑NO ❑YES �NO
BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM FEET FROM LINE( AIR INLET.
❑YES NO ❑YES ❑NO NEAREST I J
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO DYES ❑NO
GALLONSPER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF '.PROPERTY WELL. BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑N NEAREST;
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN'
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
e ya WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIUE DIA.. #PITS. LIQUID
TRENCHES. MATERIAL: lyI+� DEPTH:
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF PROPERTY WELL: BUILDING VENT TO FRESH
BELOW IPIE). ABO E COVER ELEV.INL T ELEV END. 2 PIPES FEET FROM LI AIR INLET:
/ NEARE1
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES 1:1 NO
SOIL COVER JTE.TIRE JPERMANENT MARKERS OBSERVATION WELLS.
DYES ❑NO El YES 0 N
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED.
CENTER. EDGES:
[--]YES ❑NO ❑YES ONO ❑YES I--]NO
PRESSURIZED DISTRIBUTION SYSTEM:
yH n WIDTH: LENGTH: TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEV.. ELEV.. DIA.: ELEV.. PIPES. DIA.:
ELEtdATIflN ANll3
�yI� �a..�,.,i�4 'HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
❑YES El NO ❑YES El NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: N1 , 'PROPERTY WELL: BUILDING:
FIE,,61 M, LINE:
DYES ONO ❑YES 0 NO1EARI:ST.°
L( .14
I�
Sketch System on etain in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
DILHR SBD 6710 (R.01/s2) Zoning Administrator
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 81/2 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; dosing or pumping chambers; 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.
-------------------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground dt8r—
included the creation of surcharges (fees) for a number of regulated practices which Wiscor sirt`S
can effect groundwater. The surcharge took effect on July 1, 1984- All of the water that buried reas11,
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
0
The monies collected through these surcharges are credited to the groundwater fund adminis-
teree by the Department of Natural Resources. These funds are used for monitoring grou-!d- t
eater, groundwater contamination investigations and establishment of standards. Grounewate
it's worth protecting.
SBD-6398(R.03/86)
=:ZffR_LHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code J •
....�....� STATE SANITARY PERMIT#
• 96
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. rFORIVARIANCE TION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. ❑YES 13) NO
PROPERTY OWNER PROPERTY LOCATION
B on Forrest SW % SW %, S 2 T31 N, R (or)W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER IBLOCKNUMBER SUBDIVISION NAME
n a H. Schachtener
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
00 TVOILLAGE:
II. TYPE OF BUILDING OR USE SERVED: - /W O — ���` yj
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ® New b.❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. 0 Conventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. El Seepage Bed b.0 Seepage Trench c. ❑ seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): upper 88.85
*<3 49 5 500 ower87.00 Feet ®Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank concrete 1:1 Lift Pump Tank/Siphon Chamber --- ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's ature:(No tam ) / IMPRSW No.: Business Phone Number:
r - � �� 3254 715 246-6200
Ga L. Steel
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
988 N. Shore Dr. New Richmond, Wi. 54017
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
CST's ADDRESS(Stree, ity, to e, ip ode) Phone Number:
988 N. Shore Dr. New aRichmnd, Wi. 54017 715-24 -6200
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
it I®Approved ❑ owner Given Initial rcharrgge Fee /�
Adverse Determination cad c)� W'�V 7
X. COMMENTS/REASONS FOR DISAPP OVAL:
,� I ct t_, \,2tJti u cal � ....,.. . N e ��
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
' APPLICATION FOR SANITARY PERMIT
STC - 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property r 6� rl - r'-.
Location of Property 14 x)43 3%, Section 1 , T _ N - R W
Township
Mailing Address
Subdivision Name
Lot Number
1
Previous Owner of Property
Total Size of Parcel a
'T'
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes �,-"No
Volume and Page Number as .recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. t
3. Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - -
PROPERTV OWNER CERTIFICATION
1 (We) eeAti6y that att a.tatementd on .this 6onm ane t ue to the beat o6 my (ouA)
know.!'edge; that 1 (we) am (aAe) the owneA W o6 the pnopenty de a eh ibed in .th iA
injonmattion 6onm, by viAtue o6 a waAnanty deed neconded in the 066ice of the
County RegiA teA o6 Deedd ad Document No. ; and that I (we)
pnedentty own the pnapoded 6 to 6on the sewage diApoAat dydtem lox I (we) have
obtained an easement, to nun with the above des en,i.bed pno pen ty, 6on the
condtnucti.on o6 aa.id aydtem, and the dame had been duty tecokded in the 066.iee
o6 the County RegiAten o6 Dee ad Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
AV-
DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
1
WARRANTY 77
.-- -J REGISTERS OFFICE
j This Deed, made between _Harold J. Schachtner and it
ST. CROIX CO., WIS.
Margaret J. Schachtner, his wife __-_ --___.--_ I; d. for Record this l
----------- ------------------wi- .e------ --------- - - - - - -
day aF Av ri 1 A.D. 19B�
---- --------- -------------- ------ ----
– Grantor, t R:3� A
an ry_on_N.__Forrest_and_Catherine_A. Forrest,_husband--- li Y
and_wife_as_suryiv_or----ship -_property --------------------
------------------------------------------ -
------------- ---------------------- -- -
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration-9-f- i1
one-dollar_and_other__good-_and-valuable_-considerat ions----- i RETURN TOMAKI & LUDVIGSON,S:C. ''
conveys to Grantee the following described real estate in ------ •CroiX----------- P. 0, Box 337 4,
County, State of Wisconsin: Osceola, WI 54020
Lot 4 of Certified Survey Map recorded in Volume 6,
Certified Survey Maps, on page 1607, as Document No. Tag Parcel No: -----------------------------------
406834, in the office of the Register of Deeds in
and for St. Croix County, Wisconsin; said Map covering
land in the Southwest Quarter of the Southwest Quarter (SW4 of SW4) of Section 2,
T31N, R19W; AND
i
The East One-half of the East One-half of the North One-half of the Southwest Quarter
of the Southwest Quarter (E2 of EZ of NZ of SW4 of SW4) of Section 2, T31N, R19W;
j AND
i
The East One-half of the East One-half of the South One-half of the Northwest Quarter
of the Southwest Quarter (El of Ez of S2 of NWT` of SW4) of Section 2, T31N, R19W;
i
This deed is given in satisfaction of Land Contract between parties dated June 26,
1986, recorded June 30, 1986, in Volume 745, page 198, as Document No. 413859.
T ,Oa
This .....is not -------- homestead property. ° _
(is) (is not) '
i
Together with all and singular the hereditaments and appurtenances thereunto belonging;
the title r
warrants that
is good, indefeasible in fee simple and free and clear of encumbrances
easements and restrictions of record and acts or omissions of Purchaser which may
have created liens or judgments against the property;
and will warrant and defend the same.
Aril
Dated this t r a----------------- day of P----------------------------------------, 19- 87
�^
' -----------------------------------(SEAL) - / .
----t-=�`J--------(SEAL)
Harold J. Sch chtner
---------(SEAL)
(SEAL)
Mar et J. �Schachtner
* . ` --------------- -------------------------------------
i
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
Ss.
- �-----------------------------------------
----------------- _County.
�•�, -------------------------------------
nti ate this Aril 19.87 Personall came before me this ________________day of
/____d of p----- y
' 19 the above named
------------------------------------
Allan 0. Maki
----- - --------------------------------------------------------------------- ------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN ________________________________________________________________________________
(If not- ---------------------------- ------------------------------ --------------------------------—---------------------------------------------
authorized by § 706.06, Wis. Stats.) to me known to be the person ------------ who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
It --------------------------------------------------------------------------------
MAKI & LUDVIGSONrS.C. �__Attornevs at Law
--------------------------
Osceola t WI_ 54020 Notary Public __________________________________________County, Wis.
1
-------------------------------
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: ____, 19----------)
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRa.`�TY DEED STATE RAR OF WISCONSIN Wi,eons in Leval Illank Co. Inc.
H
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' STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT �+
St . Croix County z
? t7
a
OWNER/BUYER ��y. _. t"
ROUTE/BOX NUMBER �-� ( ( _Ac' Fire Number
.CITY/STATE �� � ��°� �P �('� ,�,� �.e� t� , . ZIP ���(-�.I T
PROPERTY LOCATION: t"v1._- ' ��' ' , Section T -a l N, R_LW,
�. 1
Town of 7(i�,,,c;,- , �� St . Croix County,
Subdivision
A4"'11-t(�E Lot number
�- �'i�w�t:,,� .
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists of pumping out the septic tank every three years or sooner ,
if needed , by a licensed septic tank pumper. What you pdt into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix. County residents may be eligible to receive a grant for
a maximum of 6O% 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 systems properly
maintained.
The property owner agrees to submit to St . Croix County Zoning a
certification form, signed by the owner and by a master plumber ,
journeyman plumber , restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary) , the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. .�
0
I/WE, the undersigned , have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Office within 3 days
of the three year expiration date .
SIGNED-
DATE
o
St . Croix County Zoning Office
P.O. Box 98=
Hammond , WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address .
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test,your report must include:
1. Complete legal description;
Z. The rise section must clearly indicate whether this is a residence or commercial project;
3, MAXIMUM number of bedrooms or commercial use planned;
4, is this a new or replacement system;
5. Complete the suitability rating boxes.A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for,writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to'scale is preferred. A
separate sheet may be used if desired;
S, Make srarea ye>ur benchmark and vertical elevation reference point are clearly shown,and are permanent;
c Complete all appropriate boxes as to dates, names;addresses, flood plain data, percolation test exemp-
tion,if appropriare;
10. If the i nformation {such as flood plain;elevation)does riot apply, placer N.A. in the appropriate box;
11. Sign the form and place your cr.rrrent address and your certification nu`ri`rber;-
12. ivhkU legible copies and distribute= as reoUired. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Sail separates and Textures Other Symbols
st -
Slone (over 10") BR — Bedrock
cram Cobhle (3- 10") SS — Sandstone
gr - Caravel (undUr 3") LS — Limestone
s Sant I HGW -- High Gioundwater
Co arse Sanr perc — Eger-olation Rate
n xl Mt r3itjm .Sarrd W V;ol=
as -- S" ne 3a;rcl Blo(; 13 u.:ldrtrc;
is — tt„,m-iy Sand - Greater Than
sI Sandy Loam < Less Thaii
II — Loam-) Fan
sib -_ 4,i Lorna BI Black
5'r Sint Gy __ eras,,
Clay Loan!an! Y -- Ycliot�
cl S aelly ,'i<ay Loarn R — R? d
Silty Clay-Loam n ct - rt”,ottlas
s'c ._ &i. t (y Clay t^r1 vv,III
u - r l�y Clay fll - f.vv lime, faint
- Ciay cc common:coarse
rat P;aal i'nin rvlany, m diuna
d clistiiict
p --, prorrrinent
HV& High water level,
Six clenerai sod textures surface Evater
for liquid waste disposal GM — Bench Mark
VRP - Vertical Reference Point
TO THE OWNER:
This s ail test report is the first step ire securing a sanitary perrrait. The county or the Department may request
ci it^<cgtior? of this soil tes< io the field prior to permit rssriance. A complete set cif plans for the private
�>evvaqe system and a Berri; ? applicatkwl roes, be submitted to thr„ appropriate local authoaity in order to
r
�ar.i�3sa f (.Petr,l+t. Ttx2 rp,�,`:vt�`1?V?rr'nit r�1t�iS'! be t1l}t2.t3n9C;1 arli:;i jtOStf'F1 f�)r P4'.}r to tl"t8`st�a1-C Car �7ny C0155tK`Urtt0111.
I MENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115 P•O. BOX 7969
)
HUMAN RELATIONS \ / MADISON,WI 53707
(H63.09(1)&Chapter 145.045)
O ATI N: SECTION: TOWNS HIP/I Rk)CMY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
Sw �� 1/4 2 Al N/R 19k(or)w Somerset 4 n/a H. Schachtner
COUNTY: 'S BUYER'S NAME: MAILING ADDRESS:
St. Croix Bryon Forrest 1630 Park Ave. , New Richmond, Wi. 54017
USE DATES OBSERVATIONS MADE
NO.BEDRMS.:1COMMERCIAL DESCRIPTIONTx PROFILE DESCR TIONS: PERCOLATION TESTS:
Residence ❑New ❑Replace
3 n/a 3-25-87 1 n/a
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
0 S ❑U ®S ❑U ]S ❑U S DU SKI '1
step down trench
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: class 1 <3 Floodplain,indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS page 2 AOB
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTFXX. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 1 7.09 90.37 none >7.09 .67bl.1. 1.25bn.s.l. 5.17bn.c.s.
B- 2 6.50 90.50 none >6.50 .50bl.1. 1.00bn.sil. 5.00bn.c.s.
B- 3 7.33 92.35 none >7.33 1.00bl.l. 1.83bn.sil. 4.50bn.c.s.
B-
B- f r alte to system see 115 of 9- 7-85 copy attached
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER D PER INCH
P-
P-
P-
P_ see design rate
p
PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. upper trench=88.85
SYSTEM ELEVATION lower trench=87.00
IdLI I i _
tN
i
u
� r
E (
I
777
_.1.
j
s
1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
988 N. Shere Dr. New riehmpn4, W-i. 540-1-7 2298 715-246-6200
CST SIGNAT RE: _J
C%
`ISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
+R-SBD-6395 (R.02/82) —OVER —
t i
INDURTM OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDU STRY,, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 7969
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
L06ATI fql: SECTION: TOWNSHIP/AdJ1Ad�AfPr4l IT LOT NO.:BLK. O.: SUBDIVISI N NAME:
/4 /T_Y N/R or)W
COU OW A E:
MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. DESCRIPTION: New ❑ P TESTS:
Residence /� Replace 7 f�S
12
RATING:S-Site suitable for system U-Site unsuitable for system E]U CONVENTIONAL: MOUND: IN-GROUND : S STEM-INS-FjILL OLDING TANK:RECOMME�N EE SYSTEM:(optional)
J�VS ❑ J ❑S/L`J ❑S JJ U
If Percolation Tests are NOT required DESIGN RATE:
4 If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: 1846i!; Y .� 3 I Floodplain,indicate Floodplain elevation: j/Lj✓/ '
A 1 PROFILE DESCRIPTIONS
BORING TOTAL DEP H TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER aslaij IN, ELEVATION OBSERVED EST.HIGHEST—TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B 9/ '75 3 .oa
B-� �-'�P_JqeL� "Ag 1 ,45 e, if 5.
Flo
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD 3 PER INCH
P i ,
P- I
P-
P-.
P.
P
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
t -
�,... a
i
q'
a
! +
"r
i
i ! 1
N
Sfr�- L
I _
— -- _
ry 1
I i !
'
a
r
fi
I
I
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print : G TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
�z 98
CST SIGNATUR
FASTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/62) —OVER —
Bryon Forrest
SW4SW4 S.2T31N. R19W
Somerset, Township
IT,
IZ'
A
in
u
3
Gary L. Steel
988 N. Shore Dr.
New Richmond, Wi. 54017
MPRSW 3254