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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Lal2or and Ffuman Relations INSPECTION REPORT V irnm� <br /> Safety and Buildings Division Sanitary Permit No <br /> GENERAL INFORMATION .: <br /> (ATTACH TO PERMIT) , �I r\(^r <br /> Pert Holder's Name: ❑ C'ity���,Village Town of: State PI n ID No.: <br /> CST BM Elev.: Insp.BM Lev.: BM Description: Parcel Tax No <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic QST SQ Benchmark! <br /> Dosing <br /> Aeration Bldg.Sewer /n <br /> Holding <br /> St Ht Inlet V /o <br /> TANK SETBACK INFORMATION St/Ht Outlet b 7� <br /> TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic fd 50- �� A— NA Dt Bottom pr7 <br /> Dosing NA Header/Man. C/71 <br /> Dosing gn <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System p7•Q/3� <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width x Len t No,Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DI EN I N <br /> LEACHING manufacturer: <br /> SETBACK SYSTEM TO P/L BLDG WELL . LAKE/STREAM CHAMBER <br /> INFORMATION TYpeo A- Moa Num er: <br /> System: BED <br /> 7v?OJ 3 Jr �� �7� OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) x Hole Size x Hole 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.) <br /> Plan revision required? ❑ Yes PI No / <br /> Use other side for additional inforn4at`ion. F /Q <br /> SBD-6710(R 05/91) <br /> Date inspector's Signature Cert.No. <br />