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aWisconsln Department of Commerce PRIVATE SEWAGE SYSTEM Cou <br /> Safety and Buildings Division <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) 5Wr4ftaryPermitNo: <br /> Personal information you provice may be used for secondary purposes(Privacy Law s.15.04(1)(rrl))_ 3 <br /> Per 't Holder's Name: ❑ ty ❑ Village Town of: State Plan ID No.: <br /> C T ev_: Insp.BM Elev.: BM De ripf n:, Parc Tax No.: <br /> ,6 art U <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic cat Gocredz,, /1'06 Benchmark �52,oZi iw m <br /> Dosing <br /> Aeration Bldg.Sewer .D � � <br /> Holding St/Ht Inlet g j 9R.61 <br /> TANK SETBACK INFORMATION St/Ht Outlet 40 47776 <br /> TANK TO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet r <br /> Septic ?/Db S a5 16,rj " AIA— NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System &,S© L16 <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM D 6 C 0 0 /Q(. 76 <br /> TDH I Lift LrictioInSyetem TDH Ft <br /> Forcemain Length Dia. Illi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width `,2 Lengt No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMEN IONS 02" S5 DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type Of y1� `N �S6 A/A- OR UNIT Model Number: <br /> System: <br /> DISTRIBUTION SYSTEM C Q��' V/G!C /'yJ f <br /> Header/Manifold �,1 DistributionPipe(s) x H e ize x Ho Spacing Vent To Air Intake <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/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present.etc.) (' e OT Se`s <br /> Ifeh Sch �fi� — D wel( ons,. ;mss l/a (3A)_ <br /> ,! ArA , 4e 140 Ve-n 'na'te'tia <br /> G vrt2 L al e l oA //i,14AA - <br /> o2a2�A5 <br /> Plan revision requiredE] Yes V No / pO <br /> Use other side for additional information. �/ <br /> SBD-6710(8.3/97) Date Inspector's Signature Cert No <br />