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Wisconsin Department of Industry, , f e l)v PRIVATE SWAGE SSTEM County: <br /> Sabor fetyarid Human s Division <br /> INSPECTION REPORT Ea J^�e <br /> Safety and Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary Permit g <br /> Permit Holder's Name: ❑ City ❑ Villageown o : State Plan ID No <br /> CSTlInsp BM BM sci t : Parcel Tax No-: <br /> � io'd <br /> a- g3a5-C, <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic -7� Benchmark `0 <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 3 6D <br /> TANK SETBACK INFORMATION St/Ht Outlet 9,3(1 �a 6$ <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet .1� <br /> Air Intake <br /> Septic Cr-'>Jay /�� NA Dt Bottom 4� <br /> Dosing NA Header/Man. C;K, <br /> Aeration NA Dist-Pipe �0 �tov,j� <br /> Holding Bot-System Q„3 9-�0$ <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> ossForcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width i Length//��i No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS �a 5'U cl_�/ I DIMENSIONS <br /> SYSTEMTO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type Of Moe Number: <br /> System: $Ed ��✓r �S ash OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Id /r Distribution Pipe(s) �/ / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length _ CO Dia Length-37 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 ❑ N ❑ Yes ❑ No <br /> COMMENTS: (Inc de code discrepancies, persons present,etc.) dt <br /> �/y, � )e 1-lerevl ��00�144 IeS-Y 4AII 113 <br /> 7 a �lO�coUe Q' Ot/�� �� q <br /> ,� V;, <br /> Plan revision required ❑ Yes WNci 9 <br /> Use other side for additional information. 18 <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert No <br />