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WisconsiC.Department of Commerce PRIVATE SEWAGE SYSTEM County: <br /> Sttfety and Buildings Division INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No : <br /> Personal information you provice may be used for secondary purposes[Privacy Law,8.15.04(1)(m)]. <br /> Permit Holder's Na e: ❑ City ❑ Village X <br /> Town of: State Plan ID No.: <br /> CST BM Elev_: Insp BM Elev.: BMD yon: Parcel Tax No.: <br /> IDS,lb �cJ/ <br /> ANK INFO ATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark A).? <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet _561 16,35 <br /> TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic 7 3a > NA Dt Bottom ✓� <br /> Dosing NA Header/Man. rj- 1 +� <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand 92j 1 <br /> Mode[ Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> LossForcemain Length Dia. Fi Dist To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width/�� Length ,> No.Of T�hes PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIME N t N ! N DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type O �0N ? �1�� OR UNIT Mode Number: <br /> System: <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe($) x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia. Length Dia. 6f 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: (Includec e discrepancies,persons present,etc.) 4 <br /> J!, C 104, <br /> o <br /> ujet i CN C�Thu d`1 l�t�ecYi3A� llt+h✓'J77iurt. <br /> �) �.. <br /> (iLo��l /fes b (/�`+ flit c�ialJ 6 <br /> 6-1 <br /> Plan revision required? s ❑ No <br /> Use other side for additio I information. <br /> _Z4A�e140 <br /> SBD-6710(R.3/97) Date Inspector'sSignature Cert No. <br />