2008/06/10 - SANITARY - SAN - Other (3)

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W,sconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ,{r Safety anQ Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No : Per Holder's Name: ❑ Cit ❑ Village Town of: State Plan ID No.: �l!E)1� A114- CST BMElev : Insp. . BM Descripti �� Parcel Tax No- G -3 3 1177 (b 3 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic L/ ��i Benchmark 717 p ' ��T fin, Dosing Aeration Bldg.Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANKTO P/L WELL BLDG. Airto irintake ROAD Dt Inlet A Septic >�pp� �� if� NA Dt Bottom �. Dosing NA Header/Man. Aeration NA Dist. Pipe 50 Holding Bot.System 25Y3 PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH I Lift Friction System TDH Ft Loss II Forcemain Length Dia. HDist To well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length t, / No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth DIMENSIONS4� DIMEN I N SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING vanuacturer: INFORMATION Type Of s CHAMBER Mode Number: system: r C j ¢ , P 7 �0 pVW OR UNIT DISTRIBUTION SYSTEM Header/Manifold If Distribution Pipes) C� c� /' / xHole Size x HoleSpacing Vent To Air Intake Length / Dia I Length 3 ia. 7 Spacing (P SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No r h es persons present,etc.) COMMENTS Include code discrepancies, pdnci jr, i' ` � r Plan revision required? ci.Yes ❑ No Use other side for additional information. j j_ ' / SBD-6710(R 05/91) Date Inspector's Signature Cert.No.