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wisconsinDepartment ofIndustry, IPRIVATE SEWAM SYSTEM County: <br /> Labor m 'Human Relations INSPECTION REPORT yJJC�1eTT" <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary ermitNo: <br /> GENERAL INFORMATION �"�8 <br /> Permit Holder's Na E) City �yyVillage nTovvn of: State Plan ID No.: <br /> CST BM Elev : Insp. M Elev.: B Des ription. Parcel Tex No.: <br /> lCo Ccs- I t CST cx6-d do .o3 did <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic ) 000 Benchmark V-0 <br /> Dosing i,-k <br /> Aeration Bldg.Sewer <br /> Holding St Ht Inlet 6' 6, 6 <br /> TANK SETBACK INFORMATION fsttttrevt+et <br /> TANKTO P/L WELL BLDG. Ventto ROAD r9t Inlet— <br /> Air Intake <br /> Septic —A-7 li3 �3 t NA Dt Bottom <br /> Dosing NA Header/Man. StnC y,3� C C <br /> Aeration NA Dist. Pipe C f, l <br /> Holding Bot. System O / <br /> PUMP/SIPHON INFORMATION Final Grade C <br /> Manufacturer L Demand SQ\i #-'Z <br /> Model Number �c-)� GPM W?Zyf_ <br /> TDH Lift Friction System TDH Ft .4 <br /> Forcemain Length Sal Dia D st Towell /LA <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width r Length f No.Of Trenches PIT No Of Pits Inside Dia Liquid Depth <br /> DIMENSIONS ? Z DIMENSIONS <br /> SETBACK <br /> SYSTEM O P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type O �i '( �, �/� OR UNIT R Model Number: <br /> System: , . (:.% U 1 <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold l� Distribution Pipes) t tk r x Hole Size^ I x Hol Spa n Vent TQ An take <br /> Length _� Dia. � Length `� Dia � Spacing (�j '7 <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 I Topsoil ❑ Yes ❑ o ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes allo ( I LI rl fl >I <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert No. <br />