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Wisconsin Department of Industry, <br /> Labor and Human Relations PRIVATE SEWAGE SYSTEM ounty: <br /> Safety and Buildings Division INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Permit Holder's Name: <br /> rk, <br /> C7_ <br /> ❑ City Village Town o : State Pla ID No.: <br /> 1 ISQ S <br /> CST BM Elevh_: Insp.BM Ele BM Description: <br /> �mr It Parcel Ta No.: <br /> U Sl/J7 p3c) s3 - <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION HI FS ELEV. <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St Ht Inlet <br /> TANK SETBACK INFORMATION St Ht Outlet <br /> TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet <br /> Air Iota ke <br /> Septic �W / >501 3$,�I NA Dt Bottom <br /> Dosing NA Header/Man. <br /> 316`9V <br /> Aeration NA Dist. Pipe 3 <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> v <br /> Manufacturer ' Ile Pe-5 Demand / r� p <br /> 3�n. IIW� ,-3-35 <br /> Model Number a Vo GPM <br /> TDH Lift Friction System TDH Ft <br /> Forcemain Length QI Dia. " Dist.To Well7$� <br /> SOIL ABSORPTION SYSTEM <br /> DIMENSIONS <br /> H width Length O No./f Trenches PIT No.Of Pits nide Dia. Liquid Depth <br /> 1 N <br /> SETBACK SYSTEM TO P/L BLDG I WELL I LAKE/STREAMI LEACHING M nu acturer: <br /> INFORMATION Type <br /> d� X15v 1 , CHAMBER <br /> System: �p �5�{ �OO OR UNIT M e Num er: <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold ���� Distribution Pipes) <br /> Length pia Z_ y n / x Hole Size x Hole 5 acing Vent To Air Intake <br /> Length � Dia. �-� Spacing o� <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onl <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodde xx Mulched <br /> Bed/Trench Center Bed/Trench Edges To soil <br /> P ❑ Yes ❑ No El Yes ❑ No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> S(71� test— Ie - du "f" rneef <br /> Plan revision required? ❑ Yes ❑ No I <br /> Use other side for additional information. 9s c <br /> SBD-6710(R 05/91) Date Inspector' ignature Cert.No. <br />