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Wisconsin Department of Industry, PRIVATE SEWA SdEM County: <br /> Labor arxd Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION 30 / <br /> Permit Holder's N te: / A ❑ City ❑ Village ow-nte P <br /> )of: Stalan ID No.: <br /> CST BM Elev.: Insp-BM Elev.: BM Description: Parcel Tax No.: <br /> ,5'a 1 16 83 b' - int! /V," 2 — �, g6—0 6,10 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark Ido?93 a,83 <br /> Dosing <br /> Aeration Bldg.Sewer sj 9 �,?0 <br /> Holding St/Ht Inlet �,`O 73 <br /> TANK SETBACK INFORMATION St/Ht Outlet 1 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic 4Z NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe 6. 97 Q.6-, <br /> Holding Bot.System r/27 ��O(p <br /> PUMP/ SIPHON INFORMATION Final Grade S./7 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Forcemain Length Dia. Fead <br /> i Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width/ Length /�i No.Of Trenches PIT No.Of Pits nside Dia. Liquid Depth <br /> DIMENSIONS <br /> IMEN I N 7 �� DIMENSIONS <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM <br /> LEACHING Manufacturer: <br /> INFORMATION TypeO 66i u ( i , CHAMBER Mode Number: <br /> System: alb ✓� 3a 7 4 75Q OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold (�,tr DistributionPippe(s) fr , x Hole Size x Hole Spacing Vent TO Air intake <br /> Length lQ/' Dia / Length �Q Dia 4P Spanng (� <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.) 11 , <br /> We— �4� �/17 �l �7 �� Xlea, <br /> � CJztre lenlS � 57 �qc7[ fe- �D,,TI <br /> 11/'174ef" X (NQ/�t/%7 Z44el on <br /> sAX� � � _ <br /> Plan revision requiredC3 Yes No <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />