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Wisconsin Department of Industry, Wed (0—,W-07 /0 ( \ <br /> Labor and HumanRelations PRIVATE SEWAGE SYSTEM County: <br /> Safety and Buildings Division INSPECTION REPORT (<rneff <br /> GENfRAL4NFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> PermittHolder's Name: 3o/6"� <br /> ❑ City ❑ Flagown o : State Plan ID No.: <br /> �ehn ale <br /> CST BM Elev.: Insp.BM Elev.: BM Description: [P7arcel Tax No.: <br /> u OG �► oac/-,31ro - �a - g o <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY ---fSTATION BS HI FS ELEV. <br /> Septic (� Q Benchmark <br /> Dosing �J ,SDd IDa. /O(3 <br /> Aeration � <br /> Holding St/Ht Inlet9 <br /> TANK SETBACK INFORMATION <br /> St/Ht Outlet �' N ��r <br /> TANK TO P/L WELL BLDG. Air venIntaketto ROAD Dt Inlet <br /> Septic >/Ob/ LIDO NA ql•3� <br /> Dosing /Ob( S/QUI 38 / 1 NA Header/Man. r L{/3 Gg7? �g <br /> Aeration NA Dist. Pipe 0�2g H,3 l 7, �g <br /> Holding Bot. System ?$5'a K 77, <br /> PUMP/SIPHON INFORMATION Final Grade 10;-24 0,? 71,32-- <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Forcemain I Length DIa. f f Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> tBEDITRENCHQType <br /> Ej <br /> th f No.Of Trenches PIT No Of Pits Inside Dia. Liquid Depth <br /> N I N ( DIMEN I NCK P/L BLDG WELL LAKE/STREAMLEACHINGManufacturer: <br /> MATION CHAMBER <br /> �1�0 r 7160f J�Em ,�cTa 7 Moa Num er. <br /> OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/M nr old Distribution Pipe(s) 7� / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia. Length 3,2 Dia. y Spacing CO -2? <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. 16 09 'F2 a L� <br /> SBD-6710(R 05/91) DateInspector's S ature Cert.No. <br />