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Wisconsin Depdrtment of Commerce <br /> Safety and Buildings Division PRIVATE SEWAGE SYSTEM County, r <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be used for secondary purposes[Privacy L s.15.04(1)(m)). oZ�3?j <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> CST B lev.: Insp.BM Elev.: BM Desc 'pti Parcel Tax No.: <br /> �3 c.� lo" �0- 3a -b <br /> TA K INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic �� Benchmark 'HA U u— <br /> Dosing <br /> Aeration Bldg.Sewer a /0/, <br /> Holding St/Ht Inlet �7< fg-.S <br /> TANK SETBACK INFORMATION St/Ht Outlet ,92 3 <br /> TANK TO P/L WELL BLDG. Airir i tontake ROAD Dt Inlet <br /> A <br /> Septic � � Cry �j �/� NA Dt Bottom <br /> Dosing NA Header/Man- <br /> Aeration <br /> eader/Man.Aeration NA Dist. PipeAPO 17.l3 <br /> Holding Bot.System ,0Z-) -,-2 <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift FrictionSystem TDH Ft <br /> Loss cl <br /> Forcemain Length Dia. Fi Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length No Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONDIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION CHAMBER Model Number: <br /> System: > >g� OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Ma i o �1, Distribution Pipe(s) Ll x Hole Size x Hole Spacing Vent To Air Intake <br /> 04 <br /> Length Dia. 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.) k ractl� <br /> )6t J, <br /> Plan revision requiredC] Yes ❑ No p� <br /> Use other side for additional information. <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert.No. <br />