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WisconsinDepzrtmentofindustry, PRIVATE SEWAGE SYSTEM County: <br /> Labor d Human Relations <br /> SINSPECTION REPORT <br /> Safetyfety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan I o <br /> << fidXl , /S ✓�//T <br /> CST BM EI `/ <br /> Insp.BM Elev.: BM Descri tion: Parcel Tax No.: <br /> OF e:ec+v)c. all a e Gn6 � !� <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MA UFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic L4y.VBenchmark 0% /Li <br /> Dosing <br /> Aeration Bldg.Sewer rl�5O Q S <br /> Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht OutletVenTANKTO P/L WELL BLDG. AirI toROAD Dt InletAirIntakeSeptic 75i 4�0 �� N/- NA Dt Bottom � <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. PipeHo �6�3(0 <br /> 0 <br /> lding Bot.System la•/� ,/ �, B <br /> PUMP/SIPHON INFORMATION Final Grade ,� .Q <br /> Manufacturer Demand j 'I S/. e ?02. $0 <br /> Model Number GPM D, <br /> TDH I LiftFriction System TDH Ft a �� ,(p `QO.Loss �O <br /> Forcemain Length Dia. H Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width LengthNo-Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS75 —tip I DIMENSIONS <br /> SYSTEMTO P/L BLDG WELL LAKE/STREAM LEACHING Manuacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type O >7,11 <br /> 0 /_6/ /3Q/ � �/ OR UNIT Moa Number: <br /> System: / l% <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold /1 Distribution Pipe(s) , t / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia Length _Z Dia. _*L Spacing Co <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.) A /„ 9 RN �v 7 n / {� <br /> ORI i yid( PM Re/> d " `®•00 Aeb,� o7 G)a/! de <br /> eu} Bh? / Fhb,Ve 6ld J 2 8 — Z 6CV7yy Co J <br /> Ile.7'/J <br /> Plan revision required? ❑ Yes 51-No <br /> Use other side for additional information. Co CJ <br /> SBD-6710(R 0"1) Date Inspector's Signature Cert.No. <br />