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Wisconsin Department of Industry, PRIVATE SWAGE SYSTEM Co <br /> Labo�andHuman9elations INSPECTION REPORT �e5 �l �e7� <br /> Safet_and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit <br /> • GENERAL INFORMATION o2s�, �1, <br /> Permit Hold is ame: ❑ City ❑ Village pflovvrof: State Plan ID No.: <br /> erg Q�Se.iJ ePr�an �`� <br /> C5T BM Elev.: Insp.BM Elev.: BM Descr ption: ,/ Parcel Tax No.: <br /> �+ I G ( I vUtl . Glf I - .33 8-Da `f <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic S �/t7V Benchmark , ' ,$ Oo <br /> Dosing <br /> Aeration Bldg.Sewer 1 �� <br /> Holding St/Ht Inlet <br /> S.SS <br /> TANK SETBACK INFORMATION St/Ht Outlet 5 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake J, 3 <br /> Septic �'fj NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe Sg <br /> Holding Bot.System .J, 7• C(( <br /> PUMP/SIPHON INFORMATION Final Grade 3 76,56 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction SystemLossPad TDH Ft <br /> Forcemain Length Dia. Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Tren es PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS51DIMENSIONS <br /> SETBACK <br /> SYSTEMT P/L BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Sy Ca � i , ^ CHAMBER Model Number: <br /> System: I 3 ?sty A— OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header old 42 <br /> DistributionPl (s / [ x Hole Size x Hole Spacing Vent To Air Intake <br /> Length I Dia. Length 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 ❑ No <br /> COMMENTS: (Inclyde code di crep cies,persons present,etc.) <br /> lUb Ule�1�1��'rrreal"�h�{�a� dz� e�� , t-�i. ' <br /> ii"i�50ck � ya <br /> Plan revision required [-IYes o G� q y <br /> Use other side for additional infortion. <br /> SBD-6710(R 05/91) 1ate Inspector's Signature Cert.No. <br />