Laserfiche WebLink
J�� . S- ll;l <br /> Wisconsin Department of Industry, PRIVATESEWAGISYSTEM G%� County: <br /> La:nor angAuman Relations INSPECTION REPORT <br /> Safety and Buildings Division rhe <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION a (a /�3 <br /> e mit Holder's _ e: ❑ City Village POof: State Plan ID No.: <br /> oLi ZctC_A /a/7 ow <br /> 5 BM Ele : InBM Elev.: BM Descri tion: / Parcel Tax No <br /> sp. .: <br /> D 77 0,�20 — 413/5 -01 3 <br /> TANK INFORMATION 9LEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet , r) �7 3 <br /> TANK SETBACK INFORMATION St/Ht Outlet 1, <br /> TANKTO P/L WELL I BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic 7/()o q 3 Nfi NA Dt Bottom <br /> Dosing NA Header/Man. 7. <br /> Aeration NA Dist. Pipe -1191 < [,S <br /> Holding Bot.System 8, ,Q <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer Demand iii C <br /> Model Number GPM <br /> TD Lift I Loss Friction System TDH Ft <br /> Forcemain Length Dia. H Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH WidthLength"s-,i No.Of Tr PIT No.Of Pits Inside D . Liquid Depth <br /> DI I N l T DIM I N <br /> SYSTEM TO P/L I BLDG I WELL LAKE/STREAM LEACHING Manuacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO x 7/ C{�'p 106 N� ORLIN Moa Num er: <br /> System: �,� ! O <br /> DISTRIBUTION SYSTEM <br /> Length <br /> Headed V,f0d D ,r " Distribution Pi'� )� /i �/ xHole Size xHole Spacing Vent TO Air Intake <br /> Length t0 Da [[L" a Dia. -I 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 l Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil I ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) /,— <br /> " <br /> ervn7 � 65 7c`wl <br /> Plan revision requiredC] Yes )<No <br /> Use other side for additional information. <br /> SBD-6710(R 05/9 1) Date Inspector's Signature Can No. <br />