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/a -00 ices y/�z3 <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations <br /> Safetyand Buildings Division INSPECTION REPORT $0 r1`7- <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION 2 S'q 60 X <br /> Permit F{gIdgis Name: ❑ City Village Town o : State Plan <br /> feUe, -t- uH h(le rsorl cod IVt <br /> CST BM Elev.: Ins .BM Elev.: BM DeScri tion: Parcel ax No.: <br /> e D 8 �Jy coo <br /> TANK INFORMATION EL VATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septica ljQ Benchmark <br /> Dosing S �jjr <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet ,5$ <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt IN t <br /> Air Intake <br /> Septic 6-� z Nrr NA Dt Bottom eno <br /> Dosing 5� 8/ 13 NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> r <br /> Manufacturer hjyyfa l�, mand <br /> �014SWV <br /> Model Number i SS) a �Iv�pGPM �M 6� <br /> TDH Lift Friction I . Systems TDF �� t d 76 �# �7 �� S ,� <br /> Forcemain Length /0 / Dia. F�n Dist.To well �j <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length � / / No.Of Tr PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMEN I N J(ODIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION ypeO 5� 7V � I �j OR UNIT CHAMBER moder: <br /> System: <br /> DISTRIBUTION SYSTEM 645` <br /> Header/Manifold Distribution Pipe(s) / „ �/ xHole Size xHole Spacing Vent To Air Intake <br /> Length Dia Length � Dia I 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.) Ig1vL, / <br /> /// y ( 22 <br /> � tf�7G d i0✓/�- Qtncs, �/ � ��n) ,7 0 <br /> 44 d TY Q6t <br /> Plan revision required? ❑ Yes No <br /> Use other side for additional inform on. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />