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Wisconsin DepartmentCommerce PRIVATE SEWAGE SYSTEM County: <br /> Safety and Buildings Division <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanita P mI No.: <br /> Personal information you provice may be used for secondary purposes[Privacy Law,s.15.o4(1)(m)]. 3aS35 <br /> Permit Holder'L[Jame: ❑ City Village wn of: State Plan ID No-: <br /> 1L/l Ve Dc� t,'PS NA_ <br /> CST BM Elev.: Insp.BM Ele .: BM Descripti Parcel Tax No.: <br /> S, ne 6S-S� a <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic S'/��(J (� Benchmark a � .� .yam <br /> Dosing <br /> Aeration Bldg.Sewer -7,9 q <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet ti <br /> Septic �j p� �Zl ),� N NA Dt Bottom <br /> Dosing NA Header/Man. (ab 9s a <br /> Aeration NA Dist. Pipe 7 <br /> Holding Bot.System S = ' <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift I Loss Friction System TDH Ft <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length r� , No.Of Trenches PIT NoOfPits Inside Di;-7p <br /> iaLiquid Depth <br /> DIMENSIONS <br /> MEN I c� 1f DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION TypeO Gp , CHAMBER Moe Number: <br /> System: 7 3� r7 7�0 } /60 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani old h Distribution Pi e(s) N x Hole Size x Hole Spacing Vent To Air Intake <br /> Length lJ Dia. Length 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.) 7� 4 r <br /> P,e rm l f P6sfed- A)nW, <br /> 91d oar <br /> �— <br /> Plan revision required ❑ Yes o <br /> Use other side for additional infor a on. Iq Its ?R] A�R <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert.No. <br />