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Saft,y Department of Commerce PRIVATE SEWAGE SYSTEM <br /> a ,y'and Buildings Division INSPECTION REPORT County: <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice maybe used for secondary purposes[Privacy Law, .15.04(1)(m)]. <br /> Per Holder's Name: E] Cit ❑ Village Town o : State Plan I <br /> re I Y iu <br /> CST BM Ele ) Insp-BMER BM Descripti n: p Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic ©r� C.a Q G�'tjo Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer ��7 1t �18 <br /> Holding St/Ht Inlet J, no 1 W, <br /> TANK SETBACK INFORMATION St/Ht Outlet bat97613y <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic >16" >31 �` 3� �— NA Dt Bottom <br /> Dosing NA Header/Man. t� <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> 7721 ,58 <br /> PUMP/SIPHON INFORMATION Final Grade 70 94.5 <br /> Manufacturer Demand D N i r " <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft d G Qp , <br /> Loss H <br /> Forcemain Length Dia_ Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width N Length / No.Of renches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Ma <br /> nuacturer: <br /> INFORMATION Type O +� CHAMBER Moe Number: <br /> System: 7� 3 OR UNIT <br /> DISTRJIUJTIQ,NSYSTEM _�jl yl�; C&4V ce ee/' n,' <br /> Header /t Distribution Pipets) 1 x Hble Size ole Spacing I Vent To Air Intake <br /> Length ia. Length _.R4-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 ❑:N:o::] <br /> COMMENTS: (Include code discr a cies,persons present,etc.) <br /> n <br /> eri icX <br /> hokS jd,_1111 41C_5 Loc:M1cc� 4 ��YCcN l6 Ca '�7 � <br /> rA La4els cm �Y► -� �-�e-�- • a.2 yosp <br /> Plan revision required? ❑ Yes o <br /> Use other side for additional information. <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert.No. <br />