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yN . 16_11_q3 / ,oD <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: . <br /> Labor and Human Relations INSPECTION REPORT r <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No : <br /> GENERAL INFORMATION a0-7a3 <br /> Per it Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> Ia I C c /tet'/ <br /> CST BM El e Insp.BM Elev.: Bir Description: Parcel Tax No.: <br /> Q l -G 05- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic C— � P,t Benchmark /6 O �� <br /> Dosing <br /> Aeration Bldg.Sewer 57 �, 3-3 <br /> Holding St/Ht Inlet ,yZ „Z <br /> TANK SETBACK INFORMATION St/Ht outlet S n 3 <br /> TANKTO P/L WELL BLDG. genlntake ROAD Dt Inlet <br /> Septic 5� f A NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe V I O <br /> Holding Bot.System 7,S �7 /S <br /> PUMP/ SIPHON INFORMATION Final Grade y� �. 0 ' -� <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDHLift Friction System TDH Ft <br /> L li <br /> Forcemain Length Dia. Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width / Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM <br /> LEACHING <br /> SETBACK Manufacturer: <br /> INFORMATION Type f j CHAMBER Mode Number: <br /> System: UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/ amfoldh pe(s J <br /> , it Distribution Pi I� y x Hole, Size x Hole Spacing Vent TO Air Intake <br /> Hole <br /> Dia -��r—t Length 3 Dia. Spacing k ! <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 /> COMM NTS: (Include code discrepancies,persons present, etc.) , Ib 1 �r �e ro^,' <br /> � 11f D J <br /> Plan revision required? ❑ Yes No /® <br /> Use other side for additional infor at on. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert No. <br />