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`-h 4RS /&- l y—q5 /e 1�5_ <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and-Buildings Division aX <br /> (ATTACH TO PERMIT) Sanitary ermitNo.: <br /> GENERAL INFORMATION �" <br /> 22 <br /> Permit Holder's NamElCity L] Villa Town o : State Plan D N <br /> Io.: <br /> . �.c <br /> CST BM Elev.: Insp.BM E ev.: BM Des ription: Parcel Tax No.: <br /> o� o� Cs�� c� a-y - cL)-6co <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic POO Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet s�6 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG. Ventto <br /> Airintake ROAD D't4f at <br /> Septicr � s NA ottom 173 dl� <br /> Dosing �S` 3DI � ' NA Header/Man. �_� ,/p 00S,9R �d <br /> Aeration NA Dist. Pipe �.G 1 cis, <br /> Holding Bot.System N <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer p Demand <br /> Model Number 4 GPM <br /> TDH I Liftalige FrictionSystem _ TDH Ft <br /> Forcemain Length Dia. " Dist.To Well > <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width1\ Length �/ s PIT No.Of Pits nside Dia. Liquid Depth <br /> DIMENSIONS �T �0 IM N I N <br /> SETBACK <br /> SYSTEM TO TI P/L CHAMBER BLDG WELL LAKE/STREAM LEACHING anuacturer: <br /> INFORMATION 7ypeo Model Number: <br /> System: ) 76OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/M nifoldI Distribution Pipes) `'„ x Hoe Size x Hol S acing Vent Air Intake <br /> Length Dia. t Length r Dia. T 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/Sod ed xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes It No <br /> Use other side for additional information. <br /> SBD6710(R05/91) Date Inspector's Signature Cert.No. <br />