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Wisconsin DepartmentCommerce PRIVATE SEWAGE SYSTEM County: A <br /> Safetyand Buildings Division INSPECTION REPORT &((I <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)]. 3� <br /> Permit Holder's Name: El City ❑ Village Town of: State Plan ID No.: <br /> W� <br /> CST BM Eleu�Insp-B Elev.: BM De criRti Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer say �'20 <br /> Holding St/Ht Inlet9y,?(o <br /> TANK SETBACK INFORMATION St/Ht Outlet 7 <br /> Airri tontake <br /> TANKTO P/L WELL BLDG. AROAD Dt Inlet <br /> Septic 7 NA Dt Bottom <br /> Dosing Arm I NA Header/Man. �$ Al <br /> Aeration NA Dist. Pipe S�9 ( <br /> Holding Bot.System1 71 <br /> (p ?,�� <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction oss System TDH Ft <br /> Forcemain Length Dia. li Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SETBACK <br /> SYSTEM T P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type O a CHAMBER Model Number: <br /> System: ® 7 OR UNIT <br /> DISTRIBUTION SYSTEM o0 <br /> Header/M nifold dl Distribution Pipe(s) (4 , x Hole Size x Hole Spacing Vent To Air Intake <br /> i <br /> Length Dia. Length Dia. YL 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: (Incl�ufde odef discrepancies,pe sons preseint,etc.) �! � / `f',' ��.,� <br /> RiG[\ It'd Oe] C� pyle,7 UiY''eot S'eA0-C, ' 4 <br /> p <br /> Plan revision required [3 Yes SNo / <br /> Use other side for additional information. <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert No <br />