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Wisconsin Department of Industry, 1 : <br /> Labor and Human Relations PRIVATE SEWAGE SYSTEM / County: <br /> Safety and'Bui•.'dings Division INSPECTION REPORT Dar hem <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION ag <br /> Permit Holder's Name: ❑ City ❑ Village ErTown of: State Plan ID NO.: <br /> liUi7r zr 4 _ kS50 iL <br /> CST BM Elev.: Insp BM �e BM s ri_ptip� 7�17 Parcel Tax No.: <br /> �G' aty,j^ 0 a- 41X -2o 01101 <br /> TANK INFORMATION EL VATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS Hr FS ELEV. <br /> Septic jCSel— Benchmark <br /> Dosing <br /> Aeration Bldg.SewerQ� <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet O S <br /> TANKTO P/L WELL BLDG. Ventto <br /> Au Intake ROAD Dt Inlet �y <br /> Septic ���� //C gC� �/� NA Dt Bottom / <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe gi.� 7 <br /> Holding Bot.System 9� <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> LossTDH Lift Friction System TDH Ft <br /> Forcemain Length Dia. FI Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length//__ No. Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> I ENI N (OL) DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type O yt�� / ?/ZSj 7�/ OR UNIT Mode Number: <br /> System: / <br /> DISTRIBUTION SYSTEM <br /> Header/ManiJd ,/M Distribution Pipe(s)/ !( x Hole Size x Hole Spacing Vent TO Air Intake <br /> Length _ Dia. Lf, Length 57 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.) �i l � l— C b} .Q13,eV <br /> ta_ r I 'S C� yy'vU <br /> � <br /> A�hVe <br /> DYl M `le <br /> Plan revision requiredE] Yes bo <br /> Use other side for additional inform tion. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />