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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM county: <br /> Safety <br /> and'Hu'din sDivons INSPECTION REPORT bVr <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No. <br /> GENERAL INFORMATION 001 <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> CST M Elev.: I s .BM Elev.: BM D`,e�icriptiogg: Parcel Tax No.: <br /> e -Ce lrU'e r o0. � bm s;d�� ��f-a�C� — 000 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURE 1 �QO� CAPACITY STATION BS HI S ELEV. <br /> Septic yjS in Ve�1► ` Benchmark rl X00 <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet 1 0& 9 91 <br /> TANKTO P/L WELL BLDG. AirIntake ir ROAD Dt Inlet <br /> A <br /> Septic > Ipp� ( �{j 2 3a NA Dt Bottom <br /> Dosing NA Header/Man. 3 <br /> Aeration NA Dist. Pipe <br /> 171 <br /> Holding Bot.System �' , ��j ��. 8l <br /> PUMP/SIPHON INFORMATION Final Grade , 7 <br /> Manufacturer Demand <br /> I A <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Forcemain Length Dia.osshI Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width p Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONSf4 � DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK I CHAMBER <br /> INFORMATION Type O F� /� 3p q r s OR UNIT Mode N m er: <br /> System: ff <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake <br /> ' / �! <br /> Length �� Dia. Length 3r�y� Dia. "7 Spacing �7 ng <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: (Include code discrepancies, persons present,etc.) y�/ i <br /> Ca,5�_Zrw <br /> ro <br /> Plan revision required ❑ Yes Z No <br /> Use other side for additional information. 2— <br /> SBD-6710(R <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />