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Wisconsin Department of Commerce { I wT t* --)— C_3--C�q `O <br /> Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: <br /> INSPECTION REPORT A5Jr <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be used for secondary purposes[Privacy Law s.15.04(1)(m)]. <br /> Permit Holder's Nam ❑ City ❑ Village Town of: State Plan ID No.: <br /> 31 <br /> 111 i<e 1n or �—,—/ <br /> CST BM Elev.: Insp.BM Elev.: BM Description: 1 Parcel Tax No <br /> qg, 3� 33 - -0 - <br /> TANK INFORMATION ELEVATION D TA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark —1,50 <br /> Dosing <br /> Aeration Bldg.Sewer o2 9j`57 <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet �,(s� �3o2- <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> t�- <br /> Septic 60 i /3' r� NA Dt Bottom / <br /> Dosing NA Header/Man. ,5o $� <br /> Aeration NA Dist. Pipe l 76 <br /> Holding Bot.System 3 ,? S <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> ossForcemain Length Dia. Fi DistTowell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width i Length/ No-Of Trenc s PtT No.Of Pits Inside Dia- Ligwd Depth <br /> DIMENSIONSC0 DIMENSIONS <br /> SETBACK <br /> SYSTEMTO I P/L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type O i CHAMBER Model Number: <br /> System: �� BO -27 > S0 IVA^ OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/ nifold Distribution Pipe(s t / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia Length rDia. 7 Spacing –(P— t= � 1_� 1___� <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of x Seeded/So xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes Eypo. Yes P No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> s-/a� s� <br /> NO We,It 6n Si�� CL"1;Mg e d/ /� <br /> r <br /> Plan revision required? C] Yes Afoo 13 9$ � <br /> Use other side for additional information. IL�Ii I i/Il"�..II II <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert No <br />