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Wisconsin DepartmentCommerce PRIVATE SEWAGE SYSTEM <br /> Safety and Buildings Division <br /> County: <br /> INSPECTION REPORT /- <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rmit:�.- <br /> 'Personal information you provice may be used for secondary purposes[Privacy Law,s.15.04(1)(m)). <br /> Permit Hold isp�ame:/ _ ❑ City ❑ Village own of: State Plan ID Nq,.:, <br /> De <br /> CST BM Elev.: Insp.BM Elev.: BM Descri ti Parcel Tax No.: �1� loo <br /> 0 "-5r Dag - I/ 8 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HItFS ELEV. <br /> Septic S �, (S(Jrj Benchmark . 5g 1dd,-5� <br /> Dosing <br /> Aeration Bldg.Sewer W, <br /> �H70lding St/Ht Inlet 5�$15 <br /> TANK SETBACK INFORMATION St/Ht Outlet (0.147#,41+ <br /> etto <br /> TANKTO P/L WELL BLDG. Aiirintake ROAD Dt Inlet vt <br /> Septic /00 Z;-� I ' NA Dt Bottom (- <br /> Dosing NA Header/Man. 77 7s a, <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System 2- 946 <br /> PUMP/SIPHON INFORMATION Final Grade 5�0 68 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Lriction System Head TDH Ft opo �(O <br /> oss o <br /> Forcemain Length Did. Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length5No-O Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS a Jr DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type O �o � �5� �dOR UNIT CHAMBER Moe Number: <br /> System: ila—t4p-4 r) <br /> DISTRIBUTION SYSTEM19 — r <br /> Header/M fold ,.11/t Distribution Pipe( x Hole Size x Hole Spacing Vent To Air Intake <br /> Length �T Dia rl- 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 /> COMMENT4de ode discrepancies, persons present,etc.) �— <br /> C� ncLges <br /> Oj,�.�or "/!l <br /> �arnl� LaQ G -Z-A <br /> Plan revision required? ❑ Yes �o <br /> 14 <br /> Use other side for additional information. �Z <br /> SBD-6710(R.3/97) Date nspector's Signa re Cert No <br />