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Wisconsin Hu Department ent of corns.Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human sDivUio INSPECTION REPORT ur( <br /> Safety and Buildings Division <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> 1 -753-7 <br /> Permit Hol er's Name':// El City ❑ Village Town of: State Plan ID No.: <br /> er /forwoj �a <br /> CST BM Elev.: Insp,BM Elev.: BM Description: Parcel Tax No.: <br /> 3y <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark 3 S/ 3 ' <br /> Dosing <br /> Aeration Bldg.Sewer 1 it <br /> Holding s a 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 y{/A- NA Dt Bottom <br /> Dosing NA. NA Header/Man. <br /> Aeration N NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. ead Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION TypeO CHAMBER Model Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) 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 /> COM�EN�S: �c�d�code discre ncies, sons present,etc.) <br /> 4j/�1,rnt II�CRa4� <br /> �lQ2Yn. �:,1wv�z�K1A' . <br /> Plan revision required? ❑ Yes No <br /> Use other side for additional information. aQ <br /> SBD-6710(R 05/91) Date InspectorTsig ature Cert.No <br />