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Wisconsin Department of rndu;vy, PRIVATE SEWAGE SYSTEM 'O' l j County: <br /> Labor anal Haman Relations INSPECTION REPORT �/ 0r/ <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary P rmitNo.: <br /> GENERAL INFORMATION <br /> Perms Holder's Name: ❑ City [IVillage Town o : State Pla ID No.: <br /> Perm <br /> ° Ha - <br /> CST BM Elev.: Insp.BM EI v. BM Desc;nn: Parcel Ta No.: <br /> ✓f) <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS Ir I FS ELEV. <br /> Septic S' �}(� e"t" 8a) Benchmark 1/ <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet ,S , 6 1B <br /> TANK SETBACK INFORMATION St/Ht Outlet 3 <br /> TANKTO P/L WELL BLDG. geflntake ROAD Dt Inlet <br /> Septic x/o /a NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe a <br /> Holding Bot.System <br /> PUMP/ SIPHON INFORMATION Final Grade . / 6.6,0 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Loss Head <br /> Forcemain Length Dia. Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No.Of Trenches PIT N0.Of Pits nside Dia. Liquid Depth <br /> DIMENSIONSDIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK <br /> INFORMATION System <br /> �� 20 55 OR UNIT CHAMBER Model Number: <br /> System: <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold . it Distribution Pipe(s) y /- / x Hole Size x Hol Spacing Vent To Airintake <br /> LengthIL Dia —L7l—' Length a I Dia. Spacing & <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems C my <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sod led xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil I ❑ Yes ❑ IN o ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) I c n <br /> Cam I' e an <br /> [W] <br /> Plan revision requiredC1 Yes No <br /> Use other side for additional information. <br /> SBD-6710(R 05611) Date Inspector's Signature gg Cert.No. <br /> C <br />