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( (�y`.isconsinDepartmentofIndustry, PRIVATE $ WAGE SYSTEM ! 0 0 -County: <br /> 1'Lafet and Humdin Relations INSPECTION REPORT Ba el <br /> Safetypnd Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: , <br /> GENERAL INFORMATION �j60 � (7` <br /> Permit Hol s ame: �1 ❑ City ❑ Village own of: State Plan ID No <br /> �e,; Ai ail e r Oa Klah er/ <br /> CST BM Elev.: Insp.BM Elev.: BM Desc iptip,n: i{ Parcel Tax No.: <br /> TANK INFORMATION/V,Onw U ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION B5 HI FS ELEV. <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet 37 5,1 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> SepticGrp >5d l D f NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade 3, /7 1 gg.Dg <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> oss Head <br /> Forcemain I Length Dia. Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Lengt No.Of Trenches PIT NoOfPits Inside Dia. Liquid Depth <br /> DIMENSIONSr' — DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK I CHAMBER <br /> INFORMATION Type Of Caeveir{.`e+( Model Number: <br /> System: -. Is,, >oZrj f S�/ s7 j OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold ILA Distribution Pipe(s),' /n i x Hole Size x Hole Spacing Vent 7o Air Intake <br /> Length _V Dia. / Length32: 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 discreeppancies, persons present,etc.) C 1„d Gl o, <br /> ejee le� D 6� � �n , cJ `v v l <br /> Plan revision required ❑ Yes ANO <br /> Use other side for additional information. &V3 <br /> SBD-6710(R 05/91) Date Inspe or'sSignature Cert No. <br />