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Wisconsin Department of Industry= PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT rOat— <br /> (ATTACH <br /> Safety and buildings Division <br /> (ATTACH TO PERMIT) sanitaryPermit No.: <br /> GENERAL INFORMATION lao] c)-) <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> zfigm CSOY1 & 7 <br /> CST BM EI II BM Elev.: EBO Description: Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic 5" �j Benchmark3r U ;(j in <br /> Dosing L <br /> Aeration Bldg.Sewer 7t �J <br /> Holding St/Ht Inlet �j1CY J-o <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic ��(Y �Q/ _ l NA Dt Bottom <br /> Dosing NA Header/Man. h //i c <br /> Aeration NA Dist. Pipe lre<y � u <br /> Holding Bot. System 7,y �' fir illy <br /> PUMP/ SIPHON INFORMATION Final Grade 17"", E/ <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift :riction System TDH Ft <br /> Forcemain Length Dia. li Dist To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width .-( Length I No.Of Trenches PIT No Of Pits Inside Dia Liquid Depth <br /> DIME N SIONS (.=1 ( DIM N I N <br /> SETBACK SYSTEM TO P/L BLDG I WELL LAKE/STREAM <br /> LEACHING Manufacturer: <br /> INFORMATION TypeO p n CHAMBER Mo el Num e <br /> System: &/Vu I� � �� (dr OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe($) r= rl I x Hole Size IxHolespacing I Vent To Airintake <br /> Length I Dia _L Length 131_;� Dia. Spacing _ 57;D1U1 k 'I <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded l5odded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes ❑ No <br /> Use other side for additional information. <br /> SBD-6710(R 05191) Date Inspector's ignature Cert.No. <br />