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V erg 14 30--i 7 o <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Hyman Relations INSPECTION REPORTS/). — <br /> Satptyand BuildingsDivision � <br /> GI=NERALINFORMATION (ATTACH TO PERMIT) Sanitary Perm itNo: <br /> Pit Holder's Name: ❑ City ❑ Village Town o : State Pla ID o.: <br /> einti e,-K Ha rcw <br /> CST BM Elev.: Insp BM Elev.: BM Descriptio Parcel Ta No.: <br /> TANK INFORMATION ELEvAnON DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS H I FSrLE <br /> Septic Benchmark Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet C76 <br /> TANK SETBACK INFORMATION St/Ht Outlet 9� <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic �, NA Dt Bottom <br /> Dosing NA Header/Man. ,3 <br /> Aeration NA Dist. Pipe <br /> Holding Bot. System <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. e a li Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width LengtV3 & I No.Of Trenches PIT No.Of Pits InsideDia. Liquid Depth <br /> DIMEN I N / JJ DIMENSIONS <br /> SETBACK <br /> SYSTEMTO I I P/L j.,BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type tiJe CHAMBER -0odel Number: <br /> System: l - 7� )L:7/1 70 ' OR UNIT <br /> DISTRIBLITIO,P SYSTEM <br /> Header/Ma11 Distribution (s)/ �: x Hole Size x Hol Spacing Vent To Air Intake <br /> Length Dia. L Length Dia. Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems 0 my <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sod ed xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No <br /> COMMENTS: (Inclu code discpancies, persons present,etc.) /14r4/�9 Q� /CIA ylll <br /> Sill s4r <br /> o(¢ f <br /> _lei L <br /> Plan revision required? ❑ Yes �No <br /> Use other side for additional infor (tl in <br /> SBD-6710(R 05/91) Date Inspector's Signature I Cert.No. <br />