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Wisconsin Department of Industry, PRIVATE-S'E—WAGE SYSTEM County: _ <br /> Labor and Hum aJi Relations INSPECTION REPORT <br /> Safety and'Buildings Division <br /> 51 r <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION I 30Gq <br /> Per it Holder's Name: //',� ❑ City ElVillage Town of: State Plan ID No.: <br /> X /� <br /> J La er C N <br /> CST BM Elev.: Insp BM Lev.: BM Descripti n: Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. <br /> Septic �Qoa Benchmark JO/ a) /00 <br /> Dosing <br /> Aeration Bldg.Sewer 3,&oo q,, <br /> Holding St/Ht Inlet �j, 61721) ' <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG. Vent to ROAD Dt Inlet Lam. <br /> Air Intake <br /> Septic �p' �(P NA Dt Bottom 7� p <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System 93, 70 <br /> PUMP/ SIPHON INFORMATION Final Grade �r6 95lf0 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft �a Gry 57prh O. Q.30 <br /> Loss Forcemain Length Dia. H Dist Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH WidthQ Length '/ No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS1O 7j _Ve� DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION System: <br /> $1rD � �i p i oQ/ �las� ORUNIT Moa Number: <br /> Sysstem: / p <br /> DISTRIBUTION SYSTEM <br /> Header/Tpld N Distribution Pipe(s) !c / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia. —T Length Dia. Spacing V/ <br /> SOIL COVER It 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.).t �6/ 0� hOq� �pSe'yp /�L/5 <br /> bp {fern/.{ �osfc�— q�ya �t y l (— jC"�r'nGled 6�'i"/° i <br /> �¢u e3a , <br /> Plan revision requiredC] Yes o <br /> Use other side for additional inform tion. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />