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_ '00Wisconsin Department of industry, PRIVATE SWAGE SYSTEM County: <br /> Labor and H in Relations ot INSPECTION REPORT <br /> GENERAL INFORMATION <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Permit Holder's Na ❑ City ❑ Vi I ge Town o : State Plan ID No.: <br /> � 'Qh1e <br /> CST BM Elev.: Insp.BM EI 6Mvescription: // Parcel Tax No-: <br /> O�o -�3a3-ate 3� <br /> TANK INFORMATION ELEVA ON DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic ((� Gcnrte�i �C/� Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer +� r <br /> Holding St/Ht Inlet ,2,Ga -75 <br /> TANK SETBACK INFORMATION St/Ht Outlet v SO <br /> TANKTO P/L I WELL I BLDG. ventto ROAD Dt Inlet 7� <br /> �1 ? Air_In)take / <br /> Septic a(o S3 33/ i�11— NA DLEW w 6 1675 600 <br /> Dosing a(,/ 74 61 - 5a2/ NA Header/Man. 3 j3 10/p,Dppa//— <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System f d S �oZ <br /> PUMP/ SIPHON INFORMATION Final Grade y D , &o <br /> Manufacturer .e Li Demand <br /> Model Number I GPM <br /> TDH Lift 3' Friction S Stem�� TDH Ft <br /> L <br /> Forcemain Lengt Dia. u Dist.Tow e11 <br /> owell gam <br /> SOIL ABSORPTION SYSTEM <br /> BED/ ENC Width Length / No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> IM INS <br /> LEACHING Manu acturer: <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMBER <br /> INFORMATION Type r <br /> System: kvenb b S al0 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani old Distribution Pipes) / / /H -' x Hole Size x Hole Spacing Vent To Air Intake <br /> Length ID a:_ Length 7 S Dia. `"f 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 {� (J❑ Yes ❑ No YYes\ ❑ No <br /> COM ENTS: (includecode-dsc pang persons prsenttc.)) <br /> ,,� ttDD e <br /> �An <br /> Plan revisio uired? ❑ Yes R(NO <br /> Use other side for additional inform�t10n. <br /> SBD-6710(8 05/91) Date Inspector's Signature Cert No. <br />