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�; 6- x - iA I ( (70 <br /> Wisconsin Departm en,of Industry, PRIVATE SEWAGE SYSTEM County: ��nn <br /> Labor and Human Relations. INSPECTION REPORT <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENtRAL INFORMATION I�_M <br /> PerHolder's Name' E] City ❑ Village Town o State Plan ID No.: <br /> tTaVI D Randal <br /> CST BM Lev.: Insp.BM Elev.: BM Description: ,ZoA ( y Parcel Tax No.:G—RSOO-0,),- ql(-t) <br /> S i< I Alao' Ai 6C 7o o� 7,� �i' l �15� <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic ( ger SLy Benchmark g 160 Af4_ 10/, <br /> Dosing <br /> Aeration Bldg.Sewer 3 Q3 q7,9 <br /> Holding St/Ht Inlet <br /> r <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic O� :��25 perItJA NA Dt Bottom O <br /> Dosing NA Header/Man. j L7Cl 9�- 0 <br /> Aeration NA Dist. Pipe j CI <br /> Holding Bot.System FCS <br /> PUMP/SIPHON INFORMATION Final Grade F5k_ 9'?, q� <br /> Manufacturer Demand 1/}hKdn`�rc�` V T41 laor �� <br /> Model Number GPMg�q f <br /> TDH Lift Friction System TDH Ft Loss <br /> ead <br /> Forcemain Length Dia. H Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length i No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS /9 "�/ DIMENSIONS <br /> SETBACK <br /> SYSTEMTO P/L BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> CHAMBER <br /> INFORMATION TypeO ,`'I6y, ,/ i ` / ,� /nn model Number: <br /> System: C I!1 -7251 I/� i✓0AIA OR UNIT <br /> DISTRIBUTION SYSTEM '71000 <br /> Header/Manifold Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake <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 /> ENTS: (Include code discrepant' s,per ons p sent,et .) <br /> Si dryo � <br /> Ah -�'� <br /> Plan revision required? ❑ Yes ❑ No <br /> Use other side for additional information. �`�' <br /> SBD-6710(R 05/91) Date <br />