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Wisconsin Departmentof Industry, PRIVATE SEWAGE SYSTEM County: <br /> Lab, and Human Relations ^,�,� <br /> Sat, i and Buildings Division INSPECTION REPORT r <br /> GENERAL <br /> (ATTACH TO PERMIT) Sanitary nPermit/No: <br /> INFORMATION <br /> Permit Holder's me: ❑ City ❑ Village Town of: State Plan ID No.: <br /> St an L�cb�� <br /> CST BM Elev.: Insp.BM Elev.: BM Descrip ion: , Parcel Tax No.: <br /> S 01. tiQ 7 — ate. a lay- oma <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic p v /OOD Benchmark 3L) <br /> Dosing <br /> p <br /> � 1.3 <br /> Dosing �(� 4i,e7(—} <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 0 <br /> TANK SETBACK INFORMATION St/Ht Outlet ori <br /> TANK TO P/L WELL BLDG. Airi tontake ROAD Dt Inlet --t/ <br /> Air I <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. ` O <br /> Aeration NA Dist. Pipe /d <br /> Holding Bot.System P[) <br /> PUMP/SIPHON INFORMATION Final Grade 3, <br /> Manufacturer 2,5t I if r Demand <br /> Model Number IlGPM—d — vh ?IJ <br /> L Fi B� Qd <br /> TDH Lift v7b Friction System_ TDH Ft <br /> Forcemain Length Cj Dia. aFc Dist io weu <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH widt / Length No.Of Trenc es PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSION DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION rype0 / CHAMBER Model Number. <br /> System: J doC OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold )� I Distribution Pipe(s)/ /l 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/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Ves <br /> ❑ No ❑ Yes 0 No <br /> COMMENTS: (Include code discrepancies, perso sprresent,etc.) �� ) ) IN <br /> ral F6 <br /> `9� Oe <br /> r/��tt ,'Dn1 �f old Sysjej),_ � 7aga_ _'60 <br /> —,F9.0y (g ,�1� —�ul�, Sys F , raae - ��.y� g, <br /> q,�q - 4fk- JF,55 <br /> Plan revision required? ❑ Yes 0 No <br /> Use other side for additional information. s I q3 n . <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />