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Wisconsin Department of Health and Sooial Services
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TCPE or USE BLACK INK
A. CWNZR OF PROPERTY
Name Address (Street, City, Zip Code)
! { /
i
B. LOCATION OF PROPERTY W ERE SYST':.l1 WILL BE CCNSTRLCTED, ALTERK OR EXTENDED COUNTY ` ~ ~ '
Check One:
CITY VILLAGE LEGAL DESCRIPTION /
7 TOWNSHIP
C: IS LOCAL PERMIT REQUIRED FOR THIS WORK YES NO PERMIT NLYlfsER
J
D. SEPTIC TANK CAPACITY ?l i' Gallons NEW INSTALLATION REPLACRS ENT ADDITION
MATERIALS: Prefab Connrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial other = =r '
_ Specify)
Number of Persons to be Accommodated ` Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES k' NO
DishNasher YES NO Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUIN3ER MAKING INSTALLATION'
t 1
Name r, Address: License Number:
M
Signature of Applicant: MP RSW
Address:
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (date) Permit Number
Agent (Name) For:
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
{ fee paid. Agents wi!l forward application, the fee of $1.0(- for each septic tanK and the third sop,,
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
1. DATE RECEIVED __711 ~ 7 C ACCEPTED BY RETURNED _
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. f7 3 ~ PERMIT NO.
Yes or No
L REVIEWED BY APPROVED DAT$
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PER~IT NO.
R E P O R T O N S 0 I L. P E R C O L A T I O N T E S T
A N D S O I L B O R I N G S!
TO
DIVISION OF HEALTH - PLUMi3Z.ki SECTI6
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.209 Wis. AdainlstratSve Code
P E R C O I A T I O N T E S T
Test Depth Charaoter of Soil Hcurs Water lest Time Drop in Water LFvel Inches ,inutaa
Number Inches Thickness in Inohos Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overni. in Minutes Last P%srlod Last Period Period Onsr Inch
Example
P - 0 3611 To Soil 1011 Cla 2611 25 Yes or No 30 1/2 1/2 1/2 60
-2 j I 1~e:
RECORD DATA FROM M124RIUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Adainistrative Code.
S O I L B O R I N G S- Minimum 3611 Below reposed Abso tion S stcm
Boring Total Depth Depth to Ground Water Depth to Bodroc'k
Number Inches Observed Estimated Observed Est?-7-,ted Character of Soil with Thickness in Inches
Example
B - 0 721# 7211 Black To Soil 12" Clay 18111 Sand 1811, Gravel 241
, ,V
° ,j
31 7
C
RECORD DATA FROM MINDIUM OF 3 BORE HOLES
c\
YPE OF OCCUPANCY: /
RESIDENCE: Number of Bedrooms OTHER: (Specify) i4,10Number of Persons
FOOD WASTE GRINDER: Yes p.~ Dishwasher: Yes No Automatic Clothes Washer: Yes Nu->-,
FFUJENT DISPOSAL SYSTEM: NEW fi EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length- l~ Width` Depth Tile Size No. Lines
Seepage Pit= Inside DLsmetar v Liquid Depth
Ie the undersigned, hereby oert'fy that the percolation tests reported )n this form were made by me or under r.j super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
7 II /
NAME TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS f 1 ~Li 1 + ) ii' +1
DATE 'I SIGNATURE -1 / / yc 4
Parcel 006-1057-20-000 03/30/2007 08:49 AM
PAGE 1 OF 1
Alt. Parcel 26.31.16.391 006 - TOWN OF CYLON
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 - SCHACHTNER, JOHN A & TERESE
JOHN A & TERESE SCHACHTNER
2457 200TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description 2457 200TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 26 T31N R1 6W 40A NW NE /J Block/Condo Bldg:
y~ CcX Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) vak 2631N 16W I I -~~^O/v
SGvtac~he ~ ~aL ( ~ QC~
Notes: S t d W Parcel History: S
rn Date Doc # Vol/ age Type
~ ~'1
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 09/08/2004
Description Class Acres Land Improve Total State Reason'
AGRICULTURAL G4 35.000 5,800 0 5,800 NO 40
UNDEVELOPED G5 1.000 100 0 100 NO 1 I
OTHER G7 4.000 16,000 196,100 212,100 NO vjtl
,6-7 L4
Totals for 2007: Cl~
General Property 40.000 21,900 196,100 218,000
Woodland 0.000 0 0 / ^ J
Totals for 2006:
General Property 40.000 21,900 196,100 218,000
Woodland 0.000 0 0
-03
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512
Specials: Sc
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Parcel 006-1057-60-050 03/30/2007 08:49 AM
PAGE 1 OF 1
Alt. Parcel 26.31.16.395A 006 - TOWN OF CYLON
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
JOHN A & TERESE SCHACHTNER O - SCHACHTNER, JOHN A & TERESE
2457 200TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
s -Legal Description: Acres: 37.640 Iat: N/A-NOT AVAILABLE
SEC 26 T31 N R1 6W NW NW FKA 006-1057-60 Block/Condo Bldg:
(395) EXC CSM 15/4161
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
/
26-31N-16W NW0 NW r tn
Notes: n n Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 09/08/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 36.670 4,100 0 4,100 NO
UNDEVELOPED G5 1.000 100 0 100 NO
Totals for 2007:
General Property 37.670 4,200 0 4,200
Woodland 0.000 0 0
Totals for 2006:
General Property 37.670 4,200 0 4,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Parcel 006-1057-90-000 03/30/2007 08:50 AM
PAGE 1 OF 1
Alt. Parcel 26.31.16.397 006 - TOWN OF CYLON
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 - SCHACHTNER, JOHN A & TERESE
JOHN A & TERESE SCHACHTNER
2457 200TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 26 T31N R1 6W 40A SE NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
26-31N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
i
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
I
Valuations: Last Changed: 09/08/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 40.000 6,700 0 6,700 NO
Totals for 2007:
General Property 40.000 6,700 0 6,700
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 6,700 0 6,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Parcel 006-1057-60-100 03/30/2007 08:49 AM
PAGE 1 OF 1
Alt. Parcel 26.31.16.395A-10 006 - TOWN OF CYLON
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 - SCHACHTNER, MATTHEW J & JANEL J
MATTHEW J & JANEL J SCHACHTNER
2419 200TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 2419 200TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 2.330 Plat: 4161-CSM 15/4161 006/01
SEC 26 T31 N R1 6W PT NW NW BEING CSM Block/Condo Bldg: LOT 01
15/4161 LOT 1 2.330AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
26-31N-16W NW NW
Notes: Parcel History:
Date Doc # Vol/Page Type
09/13/2001 656493 1718/233 WD
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 09/08/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.330 15,000 268,000 283,000 NO
Totals for 2007:
General Property 2.330 15,000 268,000 283,000
Woodland 0.000 0 0
Totals for 2006:
General Property 2.330 15,000 268,000 283,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 547
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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