Laserfiche WebLink
5-1K_g3 / ):oo <br /> Wisebnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> r <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and Buildingspivision <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION oZ <br /> Permit Holder's Name ❑ Cit ❑ Village Town of: State Plan <br /> DNNo.: <br /> ch-a <br /> CST BM Elev.: Insp.BM Elev.: BM Desc)iptio : r Parcel Tax No <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark 0 8, 60 /00 <br /> Dosing // <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet J�� Q <br /> TANK SETBACK INFORMATION St/Ht outlet (p <br /> TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet ✓� <br /> Air Int�ak"e <br /> Septic `j jpp 7j[�� /Q— NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe Gi G 6 <br /> Holding Bot.System <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> oss Fi <br /> Forcemain Length Dia. Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> ia. <br /> : <br /> Liquid Depth <br /> BED/TRENCH Width . Length o.ofTrenc No Of Pits Inside D <br /> DIMENSION IMEN I N <br /> TyB�DG Manufacturer: <br /> SYSTEM P/L LEACHING <br /> SETBACK TypD CHAMBER Model Num er <br /> INFORMATION eO / lv�System: 1�D OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold /r Distribution Pipe(s)/ x Hole Size x Hole Spacing Vent TO Air Intake <br /> (� ��j i _ <br /> Length _ Dia 7 Length /d 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: (Include code discrepancies,persons present,etc.) _S Lcx- /C+7? C <br /> s�rac — <br /> Plan revision required? ❑ Yes �No <br /> Use other side for additional inform tion. <br /> SBD-6710(R 05/91) Date Ir Inspector's Signature Cert.No. <br />