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M�77 0N, <br /> Wisconsin Department of lndus(ry, 101;OD PRIVATE SEWAGE SYSTEM Count : <br /> Labor and Human Relations INSPECTION REPORT rn <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMA ION o�-Ilp�c�-s <br /> Perm i Holder's Name: El City El Village Town of: State Plan ID No.: <br /> �e �ZF(eme <br /> � Laoni 12 <br /> CST BM Elev.: Insp 3MElev.: BM Description: Parcel Tax No.: <br /> Ilam -3q1 -0H41 <br /> TANK INFORMATIO14 ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INF RMATION St/Ht Outlet <br /> TANKTO P/L ELL 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 Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Loss Head <br /> Forcemain Length Dia. Dist.Towell <br /> SOIL ABSORPTIONSYSTEM <br /> BED/TRENCH Width Length No,Of Trenches PIT No.04 Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SYSI EM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO model Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani old Distribution Pipe(s) z Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia. Length Dia. Spa( <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 ❑ Ves ❑ No <br /> COMMENTS: (Inclu a code discrepancies, persons present,etc.) <br /> Plan revision required. ❑ Yes ❑ No <br /> Use other side for addi tonal information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />