Laserfiche WebLink
f1 10 _. /q /�' -1 (G1 X <br /> Wisconsin Department of Indust I PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT �v��I� <br /> Safety and Suildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No: • \ r ,�� <br /> GENERAL INFORMATION <br /> Permit Holder's Name: ` ❑ City vilgqg� Town of: State Plan ID No.: <br /> Tcr 1 / ) .SCA <br /> CST BM Elev.: Insp.BM Elev.: BM Description. Parcel Tax No <br /> Icb /<o- �1z AS, CQTS <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark 1,06 /�, 0 (dC� <br /> Dosing <br /> Aeration Bldg.Sewer — <br /> Holding <br /> St Hit Inlet (�, x,07 <br /> TANK SETBACK INFORMATION St/Ht Outlet Ia,orj 0 <br /> TANK TO P/L WELL BLDG. ventto ROAD B51FlIeb <br /> Air Intake <br /> Septics ' 1 ��� 1 NA Dt Bottum —1 <br /> Dosing NA Header/Man. ,l s� g I• � <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System IfI.OU <br /> PUMP/SIPHON INFORMATION Final Grade 4,6-7 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Loss Forcemain Length Dia. Fi Dist-To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Ia I Length No.Of Trenches DIMENSIONSNo.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS ��ll 11 Manu acturec <br /> SYSTEM TO P BLDG WELL LAKE/STREAM LEACHING <br /> SETBACK CHAMBER Moe Number: <br /> INFORMATION TyPe Of <br /> �` / ��( <br /> System: 601n t. A4 ,t OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/M nit old (r Distribution Pi e'(�s1)r ,rfr xHole Size Ie Sp(s�I�ing Vent1TTookrintake <br /> Length _ Dia. Length _5 rL Dia. '! Spacing f/ C.7 53 <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 /> ✓Vj W2`lit!\ pa �_3 I� %^5 <br /> Plan revision required? ❑ Yes@�No <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspectors Signature Cert.No. <br />