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... . <br /> PRIVATE ONSITE WASTE TTREATMENT SYSTEMS BBamett County <br /> Asconsin c perry Address: <br /> Department of Commerce INSPECTION REPORTi ( d <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATK)N <br /> Personal infornmtion ouvide rnay be used for secon ses Pri Law,s.15.04(1 m KJ I <br /> Permit H ers Name: City Village own of: <br /> �er State Plan Transaction ID#- <br /> s <br /> CST BM Elev: Insp BM Elev: BM Description: <br /> Parcel Tax No: <br /> TANK <br /> oo E iL -FREE QQ9 a -0--q1 <br /> K INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Dosing SePfic IA] Benchmark A• 5 /b/. .00 <br /> Aeration <br /> Bldg.Sewer H #,-4L5 <br /> 9�• <br /> dding St/Ht Inlet 4 <br /> TANK SETBACK INFORMATION St/Ht outletq? <br /> TANK TO P/L WELL BLDG ANT TO ROAD 96. 28 <br /> AIR INTAKE Dt Inlet <br /> SepticD' NA <br /> Dt Bottom <br /> Dosing NA Installation <br /> Aeration Contour <br /> NA Header/Man. <br /> Holding Dist Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surf" 90 9?z, <br /> Manufacturer Demand Final Grade <br /> Model Number <br /> GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENEWNS Width (o LengthaGellsSystem Manufacturer:SETBACK P/L B av rrElnwti LEACHING <br /> INFORMATION CHAMBER <br /> !rt-9+a nd ModelCELL TO > • <br /> DISTRIBUTION SYSTEM � X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length_ Dia <br /> SOIL COVER Spat Spacing ❑Yes 0 No <br /> Depth Over Depth Over D th of <br /> Cell Center Cell Ed es t/ % Mulched <br /> To soil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> L/1.�� fi^Gw ClU ?d ,(j[...t9 Sw,� tic 2 r <br /> Permit Posted? © N <br /> Schedule 40 Vents and Observation Pipes? Y) N <br /> Cover Material: Tt/AaR <br /> Effluent Filter Manufacturer_ ; gPApr Model A -1800 <br /> Components Not Inspected: <br /> Plan revision required?I7 Yes 0 No a Oa <br /> Ui[ <br /> Use other side for additional information Date O I 3 <br /> PO S Inspector's g ature Cert No <br />