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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor acid Human RelationsINSPECTION REPORT �l/"�I�% <br /> Safety and Buildings Division Sanitary Permit No.: <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION 360 630 <br /> Permit Holder's�''e: �/ ❑ City ❑ Village own Or: State Plan ID No.: <br /> K G.hG� <br /> CST BM Elev.: Insp.BM Elev BM Des ripti�+ Parcel Tax No.: <br /> 001 <br /> 3: 2 "Ga 1" s��lo Oao - 9�S�6—o/ 7 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV- <br /> Septic Benchmark Tt <br /> DosingAeration Bldg.Sewerp,j /ioi- <br /> Holding St/Ht Inlet6.�z 7,(a- <br /> TANK SETBACK INFORMATION St/Ht Outlet �,(oS ?(V- I� <br /> TANK TO P/L WELL BLDG. ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic a-5� y �S 13.,5" NA Dt Bottom t/ <br /> Dosing NA Header/Man. r % I a— <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/ SIPHON INFORMATION Final Grade ( 7 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> oss <br /> Forcemain Length Dia. FI Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width /^/ Length/ No.O ren hes PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONSr (P DIMENSIONS <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM <br /> LEACHINGild <br /> Manufacturer: <br /> INFORMATION Type 0T_ i r� CHAMBER Mo el Number: <br /> System: >� / �5o y e� �� OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/ 'Old Al Distribution PipJ@(�10 / "T 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 ❑ Yes ❑ No ❑ Yes [] Noy�,,� <br /> CO MENTS: ( nclude code iscrepancies, persons present,etc.) <br /> 77-1 <br /> I <br /> Plan revision required ❑ Yes o ILI <br /> Use other side for additional inform'afion. �l <br /> E: <br /> SBD-6710(R 05/91) Date inSignature Cert No <br />