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7- i�, 7-5 / 1070 <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County <br /> aand Human Relations <br /> SINSPECTION REPORT &rnett- <br /> Safetfet y and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION l qr 55/O <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> CST BM Elev.: Insp.BM Elev.: BM Description: Parcel Tax No.: <br /> SSE p go1�vm 54 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUF CTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic sitJ Benchmark gg,yp 0 <br /> Dosing <br /> Aeration Bldg.Sewer h/ <br /> Holding St/Ht Inlet 0 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. AirIntake ir ROAD Dt Inlet <br /> A <br /> Septic J 1b2- S5� NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System Il Sa Y17 3,? <br /> PUMP/SIPHON INFORMATION Final Grade 0o90� �® <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift FrictionSystem TDH FtLoss <br /> Forcemain Length Dia. Fi Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length n No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONSi �t�� DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type Of / ` / CHAMBER Model Number: <br /> System: E 17 3 7 r1Q OR UNIT <br /> DISTRIBUTION SYSTEM 99" <br /> Header/M infold q Distribution Pippp���{{{s / N 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 1Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> l y n G ^�- �S 59,il!- 35 06�X <br /> pC—�ew�r1* <br /> Plan revision requiredE] Yes No <br /> Use other side for additional inform tion. <br /> SBD-6710(R 05/91) Date T Inspector's signature Cert.No. <br />