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H r 8-- 1-C13 ffm <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT &( — <br /> Safety and Buildings Division <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No <br /> Permi Older's Na e: ❑ ity ❑ ViI ge Town of: State Plan ID No-: <br /> Olin , <br /> CST BM Elev.: Insp.ggv.: BM Description: Parcel Tax No.: <br /> 1M 01- `3 CTaya 51&b 4a-250`7- / _c <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic es�q/ Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic >32) — NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe �5 <br /> Holding Bot.System Sa <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand 96 O <br /> Model Number GPM 3 � O O 3 <br /> TDH Lift Lriss System TDH Ft <br /> Forcemain Length Dia. FI Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width ,p/ Length-( No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONSDb �/! DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL I LAKE/STREAM LEACHING Manufacturer:INFORMATION yste }� ��0 n OR UNIT Moa Number. <br /> System: <br /> CHAMBER: � VQ <br /> DISTRIBUTION SYSTEM <br /> Header/M/p)nifoId Distribution Pipe(s) f / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length 7— Dia. 7 C� Length ' Dia ' Spacing <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 /> jf�p t,�r✓�j 2"T'(��e ��//fS c7``�`6� — �ZL(p�tr/te���C'1 'r�S�C�S„ <br /> Plan revision required? ❑ Yes �No <br /> Use other side for additional info(rtion. Ib I � I y3l <br /> SBD-6710(R 05/91) Date spector's Signat re Cert.No. <br />