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i � <br /> Wisconsin Department of Industry, I I pRIVATSEW GE SYSTEM County: 77�� <br /> Labor and Human Relations / INSPECTION REPORT hu6e rl?e <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION <br /> Permit Ho err's N ❑ City ❑ Village own of: State Plan ID No.: <br /> �l//JJVV/l e r Lc i S t _ <br /> CST BM ev.: Insp BM E19W BM scri tion: Parcel Tax No.: b <br /> y 0'�6— `7 3 50— 9 <br /> TANK INFORMATION ENATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. <br /> Septic Benchmark �Q , <br /> Dosing <br /> Aeration Bldg.Sewer <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 7a5� 3 7 N NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe 13, 37 <br /> Holding Bot.System ,7 2, 70 <br /> PUMP/SIPHON INFORMATION Final Grade 5,0 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. Ff DistTowell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width I �/ Length�� No.Of Trenches PIT DIMENSIONSNo.Of Pits Inside Dia. Liquid Depth <br /> DIM N 1 ^� <br /> SYSTEM TO P/L I BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK 1 CHAMBER <br /> INFORMATION TypeO Co �/ /6/ �� Model Number: <br /> System: 131z� OR UNIT <br /> DISTRIBUTION SYSTEM 49 <br /> Header/Manifold 7/ J Distribution Pipe(/s) / 4 / 1x Hole size xHole Spacing Vent TO Air Intake <br /> Length �/ Dia. Length O Dia. __Y Spacing <br /> SOIL COVER It 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 I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> nCOMENTS: Include code discrepancies, persons present,etc.) <br /> rer/vn,,T 86s4,,� <br /> 1111//((�I1111'1 � S'i7'a.r.J Ceuer <br /> Plan revision required ❑ Yes No <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />