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Wisconsin Department of Commerce <br /> Safety and Buildings Division PRIVATE SEWAGE SYSTEM county: <br /> T , - INSPECTION REPORT rp - <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be used for secondary purposes[Privacy Las. <br /> ity❑ Village 15.04(1)(m)). <br /> Permit Holder' Nie:(P 1 ❑ C_ Town of: State Plan ID No.: <br /> `V a <br /> CST BM E .. Insp.BM EI .: BM De c iption: Parcel Tax No.: <br /> /� / -Bis a—TANK INFORMATION INFORMATION EVA ION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic lfce_4 �(M Benchmark X44 <br /> p s 9a° <br /> -Aeration r Bldg.Sewer e2 �& <br /> [Holding St/Ht Inlett33 7 TANK <br /> 2- <br /> TANK SETBACK INFORMATION St/Ht Outlet Ob r!S <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic >30 53a 1114- NA Dt Bottom <br /> Dosing &h ej�-X' 3S- 11 NA Header/Man. <br /> Aeration NA Dist. Pipelrp <br /> Holding Bot.System S <br /> PUMP/SIPHON INFORMATIONFinal Grade .025 <br /> Manufacturer Aley <br /> Model Number ,S'"&1e 35GPM �h`j� e�' U, 36 $j <br /> TDH I Lift r5 Feictoss i b System TDI r(g Ft <br /> Forcemain Length'�� Dia. H 11 Dist To well 7�5-- <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Lengthrr/ No-Of Trenches PIT No Of Pits Inside Dia- Liquid Depth <br /> DIMENSIONS �oZ c7� DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type OI� l 7`s �sdCHAMBER Mode Number: <br /> y OR UNIT <br /> DISTRIBUTION SYSTEM S <br /> Header/Manif Id Distribution Pipe(s) !f x Hole Size x Hole Spacing Vent To Air Intake <br /> Length / Dia. v Length !& Dia. 41— 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 ❑ o c <br /> COMMENTS: (Include code discrepancies,crepancciies,p rsons present,etc.) b� r` C (!// <br /> cg r"Iyt <br /> Plan revision required? [] Yes kl�o <br /> Use other side for additional information- <br /> SBD-6710(R.3/97) <br /> nformation.SBD-6710(R.3/97) Date Inspector's Signature Cert No <br />