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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM 1 V nty. <br /> Labor and Human Relations INSPECTION REPORT c�he <br /> Skfety and i uildings Division <br /> (ATTACH TO PERMIT) Sanitary PermitNggy� <br /> GENERAL INFORMATION Y� <br /> Permit Ho de 's Name: �" ❑ City El Village own of: State Plan ID No.: <br /> �etI Oft-yrer <br /> CST BM Elev.: Insp.BM Eley.: BM Description: 3 labA�7-6 Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY <br /> CAPACITY STATION BS HI FS ELEV. <br /> Septic j'0 5 tr C, Benchmark ,�� �a7r Ide <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet 4L <br /> TANK TO P/L WELL BLDG. Vent to ROAD Dt Inlet "` <br /> Air Intake <br /> Septic 36 q NT NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe 4,q <br /> 6 J� <br /> Holding Bot.System %dg--- <br /> PUMP/SIPHON INFORMATION Final Grade e 4(/j �o <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift ss FrictionSystem TDH Ft <br /> Forcemain Length Dia. li Dist.ToWell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Widtb /� / LengtFYl l No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMEN i ' dL DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type ? s Model Number: <br /> System: 3 OR UNIT <br /> DISTRIBUTION SYSTEM V VV 109 <br /> Header/Manifold LI Distribution Pipe(s)__!r__ h ,, ' x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia Length Dia. __c Spacing —L <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: (Include code discrepancies, persons present,etc.) <br /> Plan revision requiredE] Yes E] No <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />