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; UD &_a, q'9 <br /> Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEMCount y <br /> Safety and,Buildings DivisionIF <br /> INSPECTION REPORT (( <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No,: <br /> Personal information you provice may be used for secondary purposes(Privacy L w,s.15.04(1)(m)]. �� <br /> Permit Hold 's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> PM n as � <br /> CST BM Elev.: Insp.BM lev: BM Description: Parcel Tax No <br /> ( .s; : I <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark q `D .y 1 �' <br /> Dosing <br /> Aeration Bldg.Sewer J 3� <br /> Holding JoCr - St/Ft S g (� <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding '/ x,25 `� Bot. System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Lori Ction System TDH Ft <br /> Head I <br /> Forcemain Length Dia. Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length NoOfTrenches PIT NoOfPits Inside Dia- Liquid Depth <br /> DIMENSIONSDIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION TypeO CHAMBERModel Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani oldDistribution 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 /> COMMENTS: (Inclu&4de dediscrepa cies, persons present,etc.) <br /> q�vj <br /> avm <br /> om4t4'r0x <br /> /0 <br /> ctlu <br /> �-� M <br /> Plan revision required? ❑ Yes "40 <br /> Use other side for additional informa �on. (� a <br /> SBD-6710(R.3/97) Date Inspector'sSignature Cert No <br />