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Wed, � I I'c� <br /> Wisconsin Department of Industry, PRIVATE SEWA E SYSTEM County: {� <br /> Labor and Homan Relations INSPECTION REPORT �l�;Ci� 'L <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary ermitNo.: <br /> GENERAL INFORMATION <br /> Permit Hder's Name: ❑ City ❑ Vil a e Town o : State Pla ID No.: <br /> CST BM Elev.: Insp.BM Elev.: B De ript q� Parcel ��.�� �� <br /> TANK INFORMATION /lls ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS 11 FS ELEV. <br /> Septic S .��,`l Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 18 44 <br /> TANK SETBACK INFORMATION St/Ht Outlet �� qe?, 44 <br /> TANKTO P/L WELL BLDG. Ve oLake ROAD ©tfMetAir <br /> Septic 7 �(jt �/}1 NA D Betl — <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot. System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. ead Fi Dist Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width I Length ' N PIT No Of Pits Inside Dia. Liquid Depth <br /> DIMEN I V J6 �r DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION TypeO / r s r CHAMBER Mo a Num er. <br /> System: CCY�.1C. t7 6 3t /_ OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold t� Distribution Pipe(s� [ / x Hole Size x Hol Sp ting Vent To it Intake <br /> Length _IL Dia- Length Dia. L 1 Spacing h ,6�'L,� S t�� <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sod Jed xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS`: (include code discrepancies, persons present,etc.) I <br /> Plan revision required ❑ Yes No C <br /> Use other side for additional information. S �� <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />