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6 - 7-93 )) " 00 <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> aand Human Relations <br /> SINSPECTION REPORT /" � %—• <br /> Safety and Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary Permit No : <br /> lq 5 L.� <br /> Permit Hq�er's Name: I I ❑ Qtv U Village Town of: State Plan ID No.: <br /> _B—M Elev.: Insp.BM Elev.: BM Des tion ///1'"II Parcel Tax No5q3- <br /> CST <br /> .�,g�x7E p .6(p De�a Si�/'n - Cb id etua0 r 3- 330%- W-yGc) <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic 000 Benchmark e/ /024 /6D <br /> Dosing <br /> Aeration Bldg.Sewer 57,3 j <br /> Holding St/Ht Inlet -'5'65' �Cn tf r <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding �� ' i o1S aC,! _f� Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM 7b d 171 ##bo/ 3..2'( L? <br /> TDH Lift Lriction System TDH ead Ft C-�a e // <br /> Forcemain Length Dia. H Dist To well 7h lC r 7ah R 57 of !&• 35r <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No.Of Trenches F—PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS I DIMEN I N <br /> SYSTEM TOP/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO Model Number: <br /> System: C UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) x Hole Sizex 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 ❑ No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> 41C r'h,t P051V r / <br /> ��oc leil�a �7%n oT jn, ecT�'� til <br /> M Id. <br /> l\ rjvtj� rtcr/"Nei' <br /> Plan revision required? ❑ Yes 1% No <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspectors Signature Cert No. <br />