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Wisconsin Department of Industry, P"AEWAlG /SVS <br /> I tM ` County <br /> Labor and Hukian Relations <br /> Safety and Buildings Division INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNo..: <br /> Permit Holder's Name: 301rC/ 30 <br /> TT <br /> El City ❑ Village own of: State Plan ID No.: <br /> �aGrJes <br /> CST BM Elev.: Insp.BMOEIevY/ BM Descrip i n ` <br /> raj (,,t,,�i/ Parcel Tax No.: <br /> o3,z -Sia 9- v/ /o <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic <br /> BO Benchmark `, v? 6F—i <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> ,7 <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANKTO P/L WELL BLDG. AirlVentontake ROAD Dt Inlet <br /> Air I <br /> SepticFT- <br /> NA Dt Bottom v <br /> Dosing NA Header/Man. lof <br /> 6 dd <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System !' <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Widthi Length No.Of Trenches PIT No.Of Pits nside Dia. Liquid Depth <br /> DIMENSIONSDIMEN I N <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION rypeo CoO CHAMBER <br /> System: _ 3 OR UNIT Mo el Number: <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) if <br /> � c'.�/. / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia. Length I Dia. / Spacing 67 <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 <br /> ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> feron� Ps ed wr'd, F �� l/ <br /> Plan revision required? ❑ Yes J)!�No <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) DateInspector's Signature `(Cert.No. <br />