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L J'-ti <br /> F21 . 10-- 1-q-?) � <br /> Wisconsin Department_flndustry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT (,( <br /> Safety anrl,Bwldings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION ] <br /> Permit Holder's Name: ❑ Cit ❑ Village Town of: State Plan ID No.: <br /> Lech n. <br /> CST BM Elev.: Insp.BM Elev.: BM De trip Ion: Parcel Tax No.: <br /> ,P 316--oq- Ick <br /> TANK INFORMATION ELEVATI N DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark �bf(- &C7 <br /> Dosing C <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe 4�1 Is, j 8T <br /> Holding Bot.System pa <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction oss System TDH Ft <br /> Forcemain Length Dia. FI Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width i Length's (� No.D nches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS4 DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION yem bi� } <br /> System: t�� >o 0706 - <br /> ORUNIT Moa Number: <br /> S <br /> DISTRIBUTION SYSTEM <br /> Header/MapifjldDistribution Pipe(s) / ( i x Hole Size x Hole Spacing Vent 7o Air Intake <br /> Length _S/L- Dia Length �� Dia Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over I 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 /> 0all I'� 05V <br /> Plan revision required? ❑ YesgI No <br /> Use other side for additional infor at on. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />