Laserfiche WebLink
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary Pe mit No <br /> Permit Hold s Name: ❑ City ❑ villag Town o : State Plan NO: <br /> c . <br /> CST BM Elev.: Insp.BM Elev.: BM Description: Parcel ax <br /> 00- <br /> TANK <br /> 0 TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION / BS HI FS ELEV. <br /> Septic Benchmark p, 13 lot 13 /00 <br /> Dosing <br /> Aeration Bldg.Sewer 6.IJ C�Cj C76 <br /> Holding St/Ht Inlet %_)ID <br /> TANK SETBACK INFORMATION St/Ht Outlet b. 66 Cc/ q <br /> TANKTO P/L WELL BLDG. ventto <br /> Airintake ROAD Bt IrtFet <br /> Septic /t)-4 NA DtAoUem <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 Loss <br /> Forcemain Length Dia. ead <br /> FI Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width \ Length PIT No,Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS ( S14 IMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING nuacturer: <br /> SETBACK CHAMBER <br /> INFORMATION System <br /> o e Num er: <br /> ystem:�OW('-� 11VA 1A � - OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold �1 Distribution Pipe(s) r� 1 x Hole x H lepa in Vent Airintake <br /> Length � Dia. � Length Sd Dia. y Spacing <br /> l <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded ISodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ N ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, per ns pres it,etc.) <br /> Plan revision required? ❑ Yes �NoLL <br /> Use other side for additional information. l Q <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />