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-j��3z& _.C7*- , do 1\9q�" 1 00 1 <br /> Wiscons-n Department of Industry, PRIVATE SEWAGE SYSTL,.r County: <br /> Labor and Human Relations INSPECTION REPORT ' <br /> ,Safety and Buildings rSivision <br /> (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION IT <br /> Permit Holder's Name: ❑ City Village KTown of: State Plan ID No.: <br /> a-le Rl� — <br /> CST BM Elev : Insp BM Elev.: BMRe riptipn Parcel ax No.: <br /> lCb X00- TT_ 'G <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark , 1e I, <br /> Dosing <br /> Aeration Bldg.Sewer S n <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 <br /> Holding ,x( 11 �a I ��S I �© Bot. System <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> ead I <br /> Forcemain Length Dia.Loss H Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK --- CHAMBER <br /> INFORMATION TypeO Model Number: <br /> System: OR U NIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) x Hole Size x H Ie 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/S dded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ElNo ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required [I Yes 1IR No me <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date J Inspe PSgntuce Cert.No. <br />