Laserfiche WebLink
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y <br /> Safety and Buildings Division Co nt <br /> INSPECTION REPORT �� <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No : <br /> Personal information you provice may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. <br /> Per t Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> CST BM E ev.> Insp. Elev.: BM De c ipt / Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV- <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer ,oZ f 9 <br /> Holding St/Ht Inlet 7 /1 3 <br /> TANK SETBACK INFORMATION St/Ht Outlet Z, a7 7,3, 73 <br /> TANK TO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet — <br /> Septic ;� ao NA Dt Bottom �- <br /> 1 <br /> Dosing NA Header/Man. -7, 39 73, 76L <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System Q <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM �b o�iM 3 <br /> TDH I LiftFFriction System TDH Ft oss HeadDT S ,3g 3 7� <br /> Forcemain Length Dia. Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width ti< Length No.Of enches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS � 37 DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG I WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION TypeO CHAMBER/ i Model Number: <br /> System: ✓�D `j50 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold ft Distribution Pipe(s) x HoleSize x H Ie Spacing Vent To Air Intake <br /> c <br /> Length A 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: (Inclu epode discrepancies,persons present,etc.) <br /> Perw <br /> &re, <br /> ° <br /> 10'ahnrnq Z- 6� �ah�r6�e <br /> Plan revision required? ❑ Yes /Tiqu-- <br /> Use other side for additional information. <br /> SBD-6710(R.3/97) Date *inspectorrtsSignature Cert No. <br />