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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM 2 ?6� County: <br /> Labor and Human Relations INSPECTION REPORT <br /> Ssfety and Buildings Division <br /> (ATTACH TO PERMIT) sanitary Permit No <br /> GENERAL INFORMATION �n <br /> Permit Holder's Name: /�� LJ Village Town of: State PlanlDNo.: ? <br /> CST BM EBM�lev: Insp. lev.: BM Description: Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic (�� _777n Benchmark /.Sj� �"f, y. /00 <br /> Dosing [ <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 77T 3,73 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG. VAienttor Intaj ROAD Dt Inlet <br /> Septic q NA Dt Bottom <br /> P j'd t? i� :�� cyc� <br /> Dosing NA Header/Man. ��•1.c� �9. d6 <br /> Aeration NA Dist. Pipe �,. �C v ,7 <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade 9J,�� 7> <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> oss id <br /> Forcemain Length Dia. FI Dist Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width b Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSION �t DIMENSION <br /> SETBACK SYSTEM TO P/L BLDG W ELL LAKE/STREAM <br /> LEACHING Manufacturer: <br /> INFORMATION TypeO r 74 7 CHAMBER Model Number: <br /> System: -F+- �-' -� r i l"'C1 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Piy(s) f / xHolesize xHole Spacing Vent TO Air Intake <br /> r/ <br /> Length _� Dia. Length —L Dia. Spaang <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Overxx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes E] No ❑ Yes ElNo <br /> COMMENTS: (Include co ediscrepancies, personspresent,etc.) <br /> � <br /> � nF trn_7t�. <br /> �VYrr 'I P 4 . i✓1l'G� I'{rU,r 1"< <br /> y J <br /> Plan revision required? ❑ Yes No <br /> Use other side for additional infornfafion. LLQ{ 11 �� �% 2' e � <br /> SBD-6710(R 05/91) Date Inspector's signature Cert.No. <br />