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Wisconsin Depart ment of Industry, PRIVATE SEWAGE SYSTEM County: <br /> 'Labor and Furman Relations INSPECTION REPORT <br /> Safgty and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary F ermitNo <br /> -: <br /> GENERAL INFORMATION <br /> Permit Holder's ame: ❑ City ❑ Villa a JQL Town of: State Plai ID No <br /> CST BM lev.: nsp.BM-Elev.: "BIM Description Parcel Tax No.: <br /> 03. 1 % a� S/Aa 60o4n <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION 85 HI FS ELEV. <br /> Septic e y GDS j(� Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic Z;-D 7�25 y� NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> l <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade 8 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. H Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> IMNI NS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TYPem C Z� C' ��i 9 OR UNIT Moa Num er: <br /> System: <br /> DISTRIBUTION SYSTEM <br /> Header/M ni IdB Distribution Pipe(s) / xHole Size xHol Spacing Vent To Air Intake <br /> Length Di, <br /> . Length 3a- 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 ❑ o ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) n 'y601 / <br /> C �` �tX /� (fir, Oa > L �/ o (ore <br /> '7 � Ale, �;�j �.h 5- ale Of <br /> W SEbi <br /> {rie&f ref t.rreq 5�1 baUlS fa Sepll'� fa ay/t F %/I �/G�c! <br /> Plan revision required? es No / �I <br /> Use other side for additi nfoformation. 7 I <br /> SOD-6710(R O5/91) Date Inspector's Signature Cert.No. <br />