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.W:,consin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Numan Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No : <br /> 4q-) 12 <br /> Perm it Holder's Name: ❑ City ❑ Village 90own o : State Pla i ID No.: <br /> L/X Si <br /> CST BM Elev.: Insp.BM Elev.: BM Description- N Parcel Ta K No.: <br /> Ion C- CSTS p -S3 3 cad-sc <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS 11 FS ELEV. <br /> SepticBenchmark <br /> Dosi ng <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet S loZ I r, 13 <br /> TANK SETBACK INFORMATION St/Ht Outlet 5. 63 R-j�a <br /> TANKTO P/L WELL BLDG. geintake ROAD Bt_h <br /> Septic T 7 >, I yf ) q+-' NA DE-Betkipt —� <br /> Dosing NA Header/Man. 7S 17, 6o <br /> Aeration NA Dist. Pipe 9?r SQ <br /> Holding Bot.System 4, <br /> PUMP/ SIPHON INFORMATION Final Grade o <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Forcemain Length Dia.Loss Fi Dist To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length 1 _ s PIT No.Of Pits nside Dia. Liquid Depth <br /> IMEN 1 36 1 1 N <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> CHAMBER <br /> INFORMATION System I !�� ��Q }�� OR UNIT Model Number: <br /> System: .� / <br /> DISTRIBUTION SYSTEM <br /> Header/Mani old s, Distribution Pipe(s� „ r x Hole Size x Hol Spacing Vent To Ai Intake <br /> Length Told <br /> Length Dia. y Spacin <br /> 9 <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sod ed xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil E] Yes ❑ o ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes (�No /1 <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date I d spector's Signature Cert.No. <br />