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6 1 : 00 <br /> Wisconsin Departmentof Industry, PRIVATE AGE SYSTEM County: <br /> Laband Human Relations INSPECTION REPORT ur <br /> Safety,and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION )-1C 3.4 <br /> Permi 1 e 's N I City . Village Town of State Plan ID No.: <br /> U r <br /> CST BM Elev.: I sp.BM Elev.: BM Descripti n CpNs. �.r Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE VNUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic 60 Benchmark <br /> Dosing Jb <br /> Aeration Bldg.Sewer ra.�y I'M <br /> Holding St Ht Inlet j0 `ID 117ff <br /> TANK SETBACK INFORMATION St/Ht Outlet v <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic /(,/A NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System j yQ <br /> PUMP/SIPHON INFORMATION Final Grade r <br /> Manufacturer Demand <br /> Model Number q V GPM <br /> TDH Lift d r FrictionLoss . ystem TDH D/ (Ft Fpft1 4)— of ou� �/ 91 ZIA <br /> Forcemain Length I(p� Dia.[Head�2 Il( I Dist To Well > <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length9 No.Of Trenches PIT No Of Pits Inside Dia. Liquid Depth <br /> DIMEN I N �O /• V-� DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Typeo r^ / > )� / model Number: <br /> System: W l ORUNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold /I Distribution Pi sY �ll �/ xHole Size xHole Spacing Vent To Air Intake <br /> Length Ja 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/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepal cigs, persons present,etc.) 17S <br /> $,35 �C/mo� <br /> 10/0 JVo luedl— Oil( - 1n&4" Ujredse `� <9 <br /> �f 'C°(ler- DP %nl QSel Yo <br /> �u�P Cj,, <br /> Plan revision required ❑ Yes ANo g <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />