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Wisconsm Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> .Labor and Human Relations INSPECTION REPORTRY <br /> Safety and Buildings Division r <br /> (ATTACH TO PERMIT) Sanitary krmit No.: <br /> GENERAL INFORMATION a 95qg <br /> Permit Holder's Name: E] City LJ Village Town of: State Pla ID No.: <br /> CST BM Elev.: InspBM v.: BM es nption: Parcel Ta No.: <br /> IC z AS CSTS 0 4 - - <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS III FS ELEV. <br /> Septic Q)CS3 ; [[ Benchmark .SQ to S /Cc <br /> Dosing S 6!? <br /> t <br /> Aeration .84dg-5ewer <br /> Holding 4liglet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. gejttake ROAD DtInlet <br /> Septic �,S y(9} y�jr yC7+` NA Dt Bottom ' j_ 00 <br /> Dosing /6t' JSY I 9 it` NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot. System �© <br /> PUMP/SIPHON INFORMATION Final Grade 6 .� <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift 3 Frictossion System _ TDH6,bt <br /> cl <br /> Forcemain I Length (Utt I Dia. ass Dist To Well t <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width \ r Length r PIT NO,Of Pits nside Dia- Liquid Depth <br /> DIMENSIONS13 3 DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING anufacturer: <br /> SETBACK I CHAMBER <br /> INFORMATION � o e Number <br /> TypeO <br /> System: CCYtuQ,, 10*j OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold tt Distribution Pip[[e(s)� y � ( xHole Si a zH I Spac- g Vent TO Air Intake <br /> Length � Dia. � Length v Dia. _�_ Spacing <br /> 4 <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 ❑ o ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Plan revision required? ❑ Yes VNo C� ` <br /> Use other side for additional information. 1EM [w J <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert No. <br />