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// <br /> Wisconsin Department rtment of Industry, PRIVATE SEWAGE SYSTEM <br /> Q✓ County: <br /> Labor and Human.Relations INSPECTION REPORT J JLC I�I� <br /> Safety and BwldingyDivision <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION aid g <br /> Permit Holder's Name: {� ❑ City ❑ Village Town of: State Plan ID No.: 11A_,�- <br /> CST BM EI Insp.BM Elev.: BM Des iptipl: Parcel Tax No <br /> TANI&NFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic �nAiCr�n Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer �, ;'� �PO 7 <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic >a6, arj, a j� NIT NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe /.a-' � - o <br /> Holding Bot.System <br /> PUMP/ SIPHON INFORMATION Final Grade l�U• �7 <br /> Manufacturer Demand <br /> Model Number GPM �o ( 5 U2 ���•6� <br /> TDH I Lift Friction SystemLoss TDH Ft <br /> Forcemain Length Dia. H Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width „ r LengthNo.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS I L K DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeOf <br /> C6 d� , 7 OR UNIT model Number: <br /> DISTRIBUTION SYSTEM <br /> Header/M nifgIld P1 Distribution Pipe( 7 / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia C Length 5O 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/Tren h Center Bed/Trench Edges `, Topsoil ❑ Yes ElNo C] Yes [I No <br /> COMMENTS: (Incl a code disc7pancies, p rsons preseWAe <br /> n <br /> I <br /> >`/,{r� Gt ) AIk l✓�L+��✓ltd . �4 <br /> �er� <br /> r ;.�,�-r <br /> Plan revision required? ❑ Yes Noj <br /> Use other side for additional informfation. � <br /> SBD-6710(R 05/91) Date I spector'sSignature Cert.No. <br />