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oo <br /> Wisconsin De me <br /> $afotyamd Buildings Division RIV E SEWAGE SYSTEM County: <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be used for secondary purposes[Privacy L w s.15.04(1)(m)]. 1210 Do <br /> Perm older's Name: , ' 1 E] C ❑ Village Town of: State Plan ID No.: <br /> Cytt <br /> CST BM Elev.: Insp.BM Elev.: BM Description (J L Parcel Tax No.: <br /> v Df- - rdSU 00 C71 — a-ao -03-7 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic s 06yutAc,;C� M Benchmark 0 ,g <br /> Dosing <br /> Aeration Bldg.Sewer , <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet 65 98.58 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic ?/9 ' >.25' /0,5 NA Dt Bottom Z, <br /> Dosing NA Header/Man. G,�d <br /> Aeration NA Dist. Pipe 700 17 /0 <br /> Holding Bot.System 718(10 <7 69, a <br /> PUMP/SIPHON INFORMATION Final Grade 6 9g:60 <br /> Manufacturer Demand <br /> Model Number I GPM S �j('Ci <br /> TDH I Lift Friction System TDH Ft <br /> Loss H , <br /> Forcemain Length Dia. Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width _ Length NO.Of Tren es PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS /� 7Ss DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer:INFORMATION Type O Lp JV pE� �� SSS � _ > las' OR UNIT CHAMBER Model Number: <br /> System: O <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold fI Distribution Pipe(s)/ ' J x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia. Length 7a Dia. `T 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 Topsoi ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discr,�pa c� s erns present,et �„�/dj,�. � , /a�2 �- <br /> lbT f I C(l G� <br /> /(/0 uJel <br /> oil 61, a re <br /> r� u/recQ <br /> L�,�IJ J�'JV Barri`' <br /> Plan revision required ❑ Yes fkNo �® Fq�y,r� r� <br /> Use other side for additional infor ton. � `( 7U / <br /> SBD-6710(R.3197) Date I spector'ssignature Cert No <br />