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WiscontinDepartment ofIndustry, PRIVAT WAGE $YSTEM County: <br /> t-hor and Human Relations INSPECTION REPORT <br /> _`afety arid Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION <br /> Permit Holder's Nam g� ❑ City Vdla a Town ci : State PI n ID No.: <br /> izi c Cs We, �1�e <br /> CST BM Elev.: Insp BM Elev.: BM Decription: Parcel T x No.: <br /> /C ��" S I� AS Cs c)U <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. <br /> Septic (� ^�` Benchmark a-? (4X? <br /> ��— <br /> Dosing <br /> Aeration Bldg-Sewer <br /> Holding St/Ht Inlet 3 <br /> TANK SETBACK INFORMATION St/Ht Outlet �f, �S C18 <br /> TANKTO P/L WELL BLDG. Ventto ROAD —Bt MIle� <br /> Air Intake <br /> Septic r � A)A NA M o�tom <br /> Dosing NA Header/Man. 11,E- <br /> Aeration <br /> 1&Aeration NA Dist. Pipe q, 19 C s <br /> Holding Bot. System y 6 CJ7, G <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift I Lriction System TDH Ft <br /> Forcemain Length Dia. Ff Dist.ToWell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width + Length ( + PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS10036 1 DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO ,t I <br /> System:�tJQ /v <_ ' A,),+ OR UNIT Model Number: <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold rs Distribution Pipe(s)r +, + z Hole Size H Ie Spacing I Vent To AnIntake <br /> Length )m Dia. � Length 3(1 Dia. Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade System5 Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil 0 Yes EINo 0 Yes 0 No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> uT r <br /> Plan revision required? 0 Yes EyNo <br /> Use other side for additional information. <br /> SBD-6710(R 0"I) Date Inspector's Signatu a Cert No. <br />