Laserfiche WebLink
Than $-a 8- N //: 30 <br /> Wis opsin Department of Commerce <br /> Buildings Division PRIVATE SEWAGE SYSTEM County: <br /> cif ty and Q <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No <br /> Personal information you provice may be used for secondary purposes(Privacy Law,s.15.04(1)(m)], g53 <br /> 8 <br /> Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.: <br /> CST BM Elev.: Insp.B,ngE v. BM Descripti Parcel Tax No.: <br /> 7 b &M I of 6 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic QSeT– C,�-ha;eAe- 756_ Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer �;' 36 <br /> Holding St/Ht Inlet , <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic X55' ��/ NA Dt Bottom <br /> Dosing NA Header/Man. 7, % ©, $ <br /> Aeration NA Dist. Pipe 790 0 <br /> Holding Bot.System <br /> —10 <br /> PUMP/ SIPHON INFORMATION Final Grade ico <br /> _ e� ,f / <br /> Manufacturer Demand e cJ• jqI110 <br /> Model Number GPM <br /> /' O <br /> TDH Lift Friction System TDH Ft _ <br /> ead <br /> Forcemain Length Dia. li Dist,To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length / No.Of TIVnches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS10 'L� DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L I BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION TypeO l �a/ // /„ ORUNIITR Model Number: <br /> System: 6 7lV <br /> DISTRIBUTION SYSTEM <br /> Header/Ma 690 M Distribution Pipe(s) i x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia- Length �0 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/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) / er- /'�/6 <br /> Nels �er .�r— (� <br /> Plan revision requiredE] Yes */ho a8 <br /> Use other side for additional information. <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert No <br />