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IIIIII <br /> Wisconsin Department of Industry, PRIVATE SE STEM <br /> Count <br /> Labor and Human Relations INSPECTION REPORT Cll"/Je <br /> Safety and'Builglings Division <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No <br /> Permit Holde 's Name: ❑ City ❑ Village Mown of: State Plan ID No.: <br /> A/� <br /> CST BM Elev.: Insp.BM Elev.: BM prription: Parcel Tax No.: <br /> / 0o2,Yy 10 Z e. Asn <br /> TANK INFORMATION LEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic le ee 6DCZ Benchmark [` /6.2 ti re76 <br /> Dosing <br /> Aeration Bldg.Sewer <br /> rHolding St/Ht Inlet y <br /> TANK SETBACK INFORMATION St/Ht Outlet 027 1 <br /> TANKTO P/L WELL BLDG- Aierintake ROAD Dt Inlet <br /> Septic >3D ' NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe �, l <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade �, t?7"z(0 <br /> Manufacturer Demand <br /> Model Number GPM , „j 106 <br /> TDH Lift Friction System ead TDH Ft <br /> Forcemain Length Dia. li Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width// i Lengthy— i No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS {oZ y `tip DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type Of > C� /� / CHAMBER Moe Number: <br /> System: ds p�J 7 //Od OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani fold �kDistributionPipe(s) ({ / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length �1 Dia Length 1 d y 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 E] No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) 'r �f <br /> _!; $1.0 <br /> A If <br /> Plan revision required? ❑ Yeso 7 <br /> © �� <br /> Use other side for additional infor tl n. �O <br /> a <br /> SBD-6710(R 05/91) Date Inspector's Sign ture Cert No <br />