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Wisconsiri.Pepartment of industry, PRIVATE SEWAGE SYSTEMcounty: <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary ermitNo.: <br /> Permit Ho ei Name' C] ity via a Town of; State P a ID No.: <br /> T BMEev.: insp. !v.' BM ¢Scriptiont Pa rce Ta No.: <br /> ,E A C%fs: 1a —C� <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS III FS ELEV. <br /> Septic �� Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer C , a <br /> Holding St/Ht Inlet Sr�' ^ <br /> TANK SETBACK INFORMATION St/Ht outlet ,1y cni <br /> TANKTO P/L WELL BLDG. Vent to <br /> Air Intake ROAD .9t-lnkk <br /> 1 <br /> Septic �'i /p 1 '>(Oi NA Dt-Betiom <br /> Dosing NA Header/Man. 6,oid (a,S3 <br /> Aeration NA Dist.Pipe d cis,99 <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade ,86 <br /> Lim <br /> Manufacturer Demand r <br /> Model Number GPM <br /> TDH I Lift Friction S stem TDH Ft <br /> LOSS I <br /> Forcemain Length Dia. Dist To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width s Length rPIT No Of Pits ns de Dia. Liquid Depth <br /> DIMENSIONS -'NT DIMENSIONS <br /> SETBACK <br /> SYSTEMTO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer:INFORMATION type /_ _ �lr OR UNIT CHAMBER o e Num r: <br /> 5 stem:�s"-7'I.Jc1 <br /> DISTRIBUTION SYSTEM <br /> Header l �ni of Distributions Pipes x Hoe ize� I x H,I, spacing IM Intake <br /> Length Dia. Length Dia. �_ Spacing r <br /> SOILCOVER x Pressure Systems Only xx Mound OrAt-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sod Jed xx Mulched <br /> Red/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ o ❑ Yes ❑ No <br /> COMMENTS: (Include code discr panciess,,pe`rsonspresent,etc.) I <br /> iirj C CtAQS 4t F: tt O� 2CT•b1 . <br /> Plan revision required? ❑ Yes 141 Nor�j <br /> Use other side for additional inform tion. <br /> SBD.6710(805/91) Date Inspector's Signature Cert.No. <br />