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Wisconsin Department of Industry, <br /> Labor and Human Relations PRIVATE SEWAGE SYSTEM County: <br /> INSPECTION REPORT Cti"rle7 <br /> S,0fety and Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Permit Holder's Name: ❑ CityVilla a Town of: State Plan ID No <br /> lL Q 7 �1 <br /> C5T BM Elev.: Insp.BM lev.: BM Descripti n: Parcel Tax No.: <br /> AIV <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic GSer QQo Benchmark ,_j l®c?,T' --1," <br /> Dosing <br /> Aeration Bldg.Sewer 7,3519`�rQB <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht outlet Jy, jd <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet - " <br /> - <br /> Septic y/dO !Z�r_ NA Dt Bottom �-- <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> LossPAH I <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / LengthIg No.Of Trenches PIT No,Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONSL2� DIMENSIONS <br /> SETBACKtj <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manuacturer: <br /> INFORMATION System:ypem �l� ��� 7t� CHAMBER <br /> Moe Number: <br /> S "! OR <br /> DISTRIBUTION SYSTEM <br /> Header/Manif�jd h Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake <br /> Length _Lff- Dia. Length -�ZZ 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/Sodd xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes C] N( ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.)F1 " <br /> Plan revision required ❑ Yes No <br /> 171361 q6 <br /> Use other side for additional infor ation. n If <br /> SBD-6710(R 05/91) Date nspedor's5ignature Cert No <br />