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Wisconsin Department of Commerce (P ' <br /> Safety and Buildings Division PRIVATE SEWAGE SYSTEM County' <br /> INSPECTION REPORT ,+rp� <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit <br /> lNo.: <br /> Personal information you provice may be used for secondary purposes[Privacy JyP�(p w, .15.04(1)(m)]. gc3L(ep <br /> Permit Ider's Name: E] City Village Town of: State Plan ID No.: <br /> Co�� <br /> CST BM Ele .:- Insp.BM Elev.: BMD ip i n: Parcel Tax No.: <br /> 01,6 All- Ola- Oi- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark Z C?7� <br /> Dosing <br /> Aeration Bldg.Sewer / <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet <br /> Air Intake <br /> Septic >3b� b A' NA Dt Bottom _ <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe S/ <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade 98.9 <br /> Manufacturer Demand Q <br /> Model Number GPM a a Se 1..1(p 0-01 D <br /> TDH I Lift Friction System TDH Ft <br /> oss Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length5bl No.Of Trenches PIT No.Of Pits Inside Dia- Liquid Depth <br /> DIM N I `� DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. <br /> SETBACK CHAMBER <br /> INFORMATION System: <br /> e <br /> Type Of <br /> y �p �}3 70/ �80 OR UNIT Mo el Number: <br /> V �3 <br /> DISTRIBUTION SYSTEM <br /> Header/manifold Distribution Pipe(s) / i s x Hole Size x Hole Spacing Vent To Air Intake <br /> Length /!q Dia t— Length Dia Y Spacing IQ <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: Ainclude code discrepancies,persons present,etc.) <br /> no <br /> Plan revision required? ❑ Yes k;.-No _ <br /> Use other side for additional inforMalion. <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert No. <br />