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)- 1-7-Tj II . 15 <br /> Wisconsin pepartment of industry, I PRIVATE SEWAGE SYSTEM FState <br /> : <br /> Labor and Human Relations INSPECTION REPORT W-fie4 <br /> Satse:y and Buildings Division y Permit No.: <br /> (ATTACH TO PERMIT) a� . g a7 <br /> GENERAL INFORMATION <br /> Permit Holder's Na : ❑ City ❑ Village own o : lan ID No.: 10 <br /> awes (Dor ren Sao <br /> Parcel Tax No.: <br /> CST BM EI .. Insp-BM Elev.: BM D scrip on: ®M O^ a <br /> TANK INFORMATION , c/�vIELEVATION DATA [7 <br /> TYPE MANUF TURER CAPACITY STATION BS I <br /> //��,rHI FS ELEV. <br /> Septic s Benchmark t7q 07 <br /> Dosing <br /> Bldg.Sewer 3.7f ,x <br /> Aeration <br /> Holding St/Ht Inlet q S"e5 <br /> / <br /> TANK SETBACK INFORMATION St/Ht outlet a: <br /> vent to ROAD Dt Inlet <br /> TANK TO P/L WELL BLDG. Air lntake <br /> Septic i7/ > a5 NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist.Pipe S <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade , <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length NX_O�es PIT <br /> N I N No.Of Pits Inside Dia. Liquid Depth <br /> DIMEN I N LEACHING Manufacturer: <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMBER <br /> Model Num er: <br /> INFORMATION Type O t (� y OR UNIT <br /> System: v <br /> i <br /> DISTRIBUTION SYSTEM <br /> Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake <br /> Header/Ma .� h S0� <br /> Length Dia. Length Dia. Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> De th Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> [Depth Over p Yes ❑ No El Yes ❑ No <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ <br /> COMMENTS: (Include cod discrepancies,persons present,etc.) �e) y,�� Poi /! <br /> Plan revision required? ❑ Yes ❑ No /� n I Jai 71 <br /> Use other side for additional information. F-771 "/ DCert. <br /> NoSBD-6710(R 05/91) Date Inspector's Signature No <br />