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q-13—q3 /l, <br /> Wisconsin,Department of industry, _ PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT r <br /> GENERAL INFORMATION <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> �"I S <br /> Pe t Holder's Name: ❑-G-tyr� Village Town of: State Plan ID No : ,f <br /> 1 �l� J Son A i <br /> CST BM EI v.: Insp.BM Elev.: BM Description: Parcel Tax No.: <br /> o a.a9 <br /> 0 61fdo Q- C7 - - <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Ser Benchmark a,�9 /42•a /�� <br /> Dosing <br /> Aeration Bldg.Sewer 6b9 63 <br /> Holding St/Ht Inlet 7 lize, 7513Y <br /> TANK SETBACK INFORMATION St/Ht Outlet 19_6 I (6 [� <br /> TANKTO P/L WELL BLDG. ventto <br /> An Intake ROAD Dt Inlet --1 <br /> Septic 1 i NA Dt Bottom ' Z <br /> Dosing NA Header/Man. a- 9 <br /> Aeration NA Dist. Pipe -7& 93 <br /> Holding Bot. System Id,/ 0 <br /> PUMP/ SIPHON INFORMATION Final Grade 7,3n <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System ead TDH Ft <br /> Forcemain Length Dia.oss i Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Lengt No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS �� `1.�- DIMEN I N <br /> SETBACK <br /> SYSTEM TO P/L I BLDG WELL I LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION I Typea // y / CHAMBER Model Number: <br /> System: C� ? 60 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/ anifold Distribution Pipe(s)� !I J x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia � Length I Dia. Spacing Cfi <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Ofxx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes <br /> ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies,persons <br /> r/present,etc.) <br /> 7 '(2 J�O C�eII ¢ ilhe Qr165" ei0q/ a— U <br /> 'P�YkV)( + YOS 12G� <br /> Plan revision required? ❑ Yes KNo r <br /> Use other side for additional information. MEN 1�3 � <br /> SBD-6710(R 05/91) Date inspector's Signature Cert.No. <br />