Laserfiche WebLink
/0-9,b-,7,3L, <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT r <br /> Safety anc�Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> )O <br /> Permit Holder's Name: EI-Qty ❑ Village Town of: State Plan ID No.: <br /> - 1a 5 k - <br /> CST BM Elev.: Insp.BM E ev.: BM Descriptio : Parcel Tax No.: <br /> ;6b ' d Sfy - = 0a- <br /> TANK INFORMATION fLEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> SepticBenchmark <br /> t Q �Q7 o O <br /> Dosing C&?cr"-rp P <br /> Aeration Bldg.Sewer — <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet — <br /> TANKTO P/L WELL BLDG. ventto Au Intake ROAD Dt Inlet <br /> Septic NA Dt Bottom �– <br /> Dosing NA Header/Man. 1 7 <br /> o <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System 8 yS, 9Q <br /> PUMP/ SIPHON INFORMATION Final Grade Vi7f /0�7, 40 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No Of Trenches PIT No.Of Pits Inside Dia Liquid Depth <br /> DIMENSIONS 112Q DIMENSION <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION TypeO D O. ,�, >S�� CHAMBER Model Number: <br /> System: NA _ OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold v Distribution Pipe(s)' It / 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: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes A,\No <br /> Use other side for additional information. Q ro <br /> SBD-6710(R 05N1) Date IIIInspector's Signature Cert.No. <br />