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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and H BJ` Relations INSPECTION REPORT 73w <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Permit Holder's Name: ❑ City ❑ Village Town f: State Plan ID No <br /> 11 - To /Veer,00 <br /> CST B lev.: Insp.BM Elev.: BM DescriParcel Tax No.: <br /> O .D p£o kJ C 0/0- 33ag-oa foo <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY <br /> �� STATION BS �HII FS ELEV. <br /> Septic Lw Benchm rk �3 D Y (JL1 <br /> Dosing <br /> Aeration Bldg.Sevier <br /> Holding St/Ht Inet <br /> TANK SETBACK INFORMATION St/Ht O itlet 9 Z-5-7 <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic 7/00 NA Dt Bottc m <br /> Dosing NA Header/Man. (y,7f} 7,3_3 <br /> Aeration NA Dist. Pip 1,023 <br /> Holding Bot.Syst m �� g'6,-31 <br /> PUMP/SIPHON INFORMATION Final Gri deq�J <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift I Loss II <br /> Friction System TDH Ft <br /> Forcemain Length Dia. F( Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length / No.Of renches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIM N 1 �Z S� DIM N INS <br /> SYSTEM TO P/L BLDG WELL LAKE/ST LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION T peo Moa Num er: <br /> System: 6°'a' SO OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/M ni h Distribution Pipe(s� C( / Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia. V Length Dia. Space <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 <br /> ❑ Yes [I No <br /> COMMENTS: (Include code discrepancies,/p�ersons present,etc.) �d <br /> �dwe-11 rzi 7t/�ne OT Iiyeo�aIJ �j <br /> 0L 14'IYIe df /�7yec�lBF) r <br /> r <br /> Plan revision requiredC] Yes $No <br /> Use other side for additional infor tion. <br /> SBD-6710(R 05/91) Date Inspector's Sig natu re C <br />