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6 -s-93 ro �")o <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Hurnan Relations INSPECTION REPORT (' <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION I Ig5y2>� <br /> Perm i older's Name: ❑ City ❑ Village Town of: State Plan ID No <br /> 6S W tzars d 9 Sia ao33 <br /> CST BM Elev.: Insp.BM Elev J BM Des ton Parcel Tax No.: <br /> rf_ {e I I �ol�I L1 ` + o #arrr S4i — - a <br /> - 03- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic a poo Benchmark . 3, 00 <br /> Dosing ` <br /> Aeration Bldg.Sewer _50 1717,51 <br /> Holding St/Ht Inlet �Q <br /> TANK SETBACK INFORMATION St/Ht Outlet c <br /> TANKTO P/L WELL BLDG. Vent to <br /> Air Intake ROAD Dt Inlet <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding a t d � Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> ossForcemain Length Dia. H Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No.Of Trenches PIT No Of Pits Inside Dia- Liquid Depth <br /> DIMEN I INS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO model Number: <br /> System: 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 ❑ No <br /> Use other side for additional information. L/ <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />