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­7Aaps 11 - 113c) <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: QQ� � <br /> Labor and Human Relations <br /> Safety and Buildings Division INSPECTION REPORT X.X�'r072� <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION / sgC__Z <br /> Permit Holder's Name: ❑ City ❑ Village Wown of: State Plan ID No <br /> @L/,,c( 32r! <br /> CST BM E lev Imp.BM Elev.: BM Description:: Parcel Tax No.: <br /> 5-n,n� 1 /01- / (jocE.am oT nb/if X29— G13 i-05-7( <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION B5 HI FS ELEV. <br /> Septic Fv8t7q (r�C sd Benchmark r; y p'•� 00 <br /> Dosing <br /> Aeration Bldg.Sewer 349 <br /> Holding St/Ht Inlet V-;4 5,10 <br /> TANK SETBACK INFORMATION St/Ht Outlet 5" %002 q5,5o <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic �/ 30� N NA Dt Bottom <br /> Dosing NA Header/Man. 7� 9�, 7� <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System ,lj0 9 <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift FriL.ction System 7DH Ft <br /> Forcemain Length Dia. FI Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width , Length No.Of Trenches PIT No.04 Pits Inside Dia. Liquid Depth <br /> DIMENSIONS � _11i DIMENSIONS <br /> SYSTEM TO P/L BLDG , WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACKCHAMBER <br /> INFORMATION yem <br /> S �a 1 T`7" 17 7��o Mode Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold q Distribution Pipes) rt x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia Length ? Dia. Span <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (�IncludeScofdedis repancies,persons present et .) I — - <br /> P ^ rGJ a1�erei e n? /Vy6 , 0 - <br /> 2 <br /> , <br /> Plan revision required? ❑ Yes (� No <br /> Use other side for additional info/ atlon. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert No. <br />