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6 7 LL <br /> wisconsi.,Departmentof Industry, PRIVATE SEWAGE SYSTEM County: i 1 <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary ermitNo : <br /> GENERAL INFORMATION )of <br /> "KU <br /> rm t oI er's N me: ❑ City ❑ Vil a e T wn of: State Pla ID No.: <br /> 11 ti Ile OCA C. <br /> CST /Eley.: Insp�C'ev.: BM Deseriptw— C�rt P^r\0 x N <br /> TANK INFORMATION ELEVATION DATA 0 <br /> 7 <br /> TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. <br /> Septic /4,A C_ Benchmark I_Sdl /O _o) 1clin <br /> Dosing <br /> Aeration Bldg.Sewer �. <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet 3. 10 <br /> TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet <br /> Air Intake <br /> Septic �S t ��s' 'O' /Qr NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot. System yd <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number ead <br /> GPM <br /> TDH Lift Friction System TDH Ft <br /> Forcemain Length Dia. H Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Trenches PIT No.Of Pits ` Inside Dia. Liquid Depth <br /> DIMEN I INS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO Model Number <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) x Hole Size x Hol Spacing Vent To Atrintake <br /> Length Dia. Length 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/So ded xx Mulched <br /> Red/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ 140 ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes D�No I� \✓ 1 <br /> Use other side for additional information. Fs l / <br /> SBD-6710(R 05/91) Date Inspect hSignature Cert.No. <br />