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'n2r <br /> Wisconsin gepartmentof Industry, TE SEwA�/S) TMounty//k: <br /> QQ <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION --Z)ig)C, <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> Ls§Ke <br /> CST BM Elev.: lrrsp.BM Elev.: BM Description: Parcel Tax No.: <br /> SR�E /03.34, -A- - <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION B5 HI FS ELEV. <br /> Septic Benchmark (� 0 .3led <br /> Dosing <br /> Aeration Bldg.Sewer $T-,?_ 9 /• <br /> Holding K w ;200C) St/Ht Inlet 7 i ,025 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding ��! <br /> j aUi / Bot.System <br /> PUMP/ SIPHON INFORMATION Final Grade S�f� �d r <br /> Manufacturer Demand � ho�.� 3• `�d , 8� <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> oss mead <br /> Forcemain Length Dia Dist To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO model Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe($) x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia 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 ISodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (includecode discrepancies,personas present,etc.)/ r7 1 L4� <br /> ferro 54 / <br /> Plan revision required? ❑ Yes MNo Ci ,S <br /> Use other side for additional inform tion. Z <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />