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OtE <br /> Wisconsin Department of Industry, PRIVAT S SYSTEM County: <br /> Labor and Human Relations <br /> Safety and Buildings Division INSPECTION REPORT 41-17e <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> 301015-C <br /> Permit Holder's Name: ❑ City [I Village Town o : State Plan ID No.: <br /> �o r�+A ��- <br /> CST BM EI Insp.BM E 6 escri iorl: Parcel Tax No.: <br /> A2 ma- 6 3.;2- q.3So -o/ 6 <br /> TANK INFORMATION tLEVATION DATA <br /> TYPE MANUFACTURER 7 CAPACITY STATION BS HI FS ELEV. <br /> Septic or u)eS'C6 1� /� Benchmark jog <br /> Dosing <br /> Aeration Bldg.Sewer Qg ep , j� <br /> Holding St/Ht Inlet 4.3 fg.Of <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANKTO P/L WELL BLDG. Aelntake to ROAD Dt Inlet 7"5�)6 <br /> Septic 7 30' ;� G,6 �} NA Dt Bottom <br /> Dosing NA Header/Man. . 9�$� <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System P 3, <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> oss d I <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width 1.121 <br /> 9 / Lengtt / No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS d— Pt DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG I WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION TypeO C.0) � i i CHAMBER Model Number: <br /> System: i�,6 i 3Z y 50 OD OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/M ni s1d d Distribution Pipe(s)� (� /I x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia ' Length o Dia. I 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 discrepancies pers ns present,etc.) / /1� <br /> �i ��` °' <br /> Plan revision required? ❑ Yes Itf No <br /> Use other side for additional information- <br /> SBD-6710(R <br /> nformation.SBD-6710(R 05/91) Date Inspector's Signature Cert No <br />