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Wisconsin Department of Industry, <br /> Labor and Hamman Relations PRIVATE SEWAGE SYSTEW County: <br /> Safety acid Buildings Division INSPECTION REPORT a/-r7e <br /> ' (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION 900603 <br /> Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.: <br /> CST BM Elev.: Insp-B Flev.: BM Descf do Parcel Tax No.: <br /> N 6a - airy-oY7 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic /�J Benchmark00 <br /> Dosing <br /> Aeration VU <br /> Bldg.Sewer R- 7y2 Jxn.7 B <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake _ <br /> Septic NA Dt Bottom l �v 6 J 1, 2S <br /> Dosing7�j� 'a NA Header/Man. Sag G,a� <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade 9 <br /> Manufacturer .7,oel a lgllpm <br /> DemcInd <br /> Model Number A/,, a5 <br /> TDH I Lift Friction � / System �1 TDHa7� <br /> LossFI 0( <br /> Forcemain Length Dia. 9n Dist.To v4elil J Jr <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width / Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS /ti DIMENSIONS <br /> SYSTEM TO /L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type 0 ]�� .) �� 3�0 OR UNIT Model Number: <br /> System: 7CJ <br /> DISTRIBUTION SYSTEM <br /> Header) ani old 1 DistributionPipe(s) / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length _ Dia.C/ Length /Dia. pacing <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 Cent. C, I.� Bed/Trench Edges Topsoil ❑ Y s ❑ No Yes ❑ No <br /> COMMENTS: (Include coded' crepan 'es,p rsons present,etc.) <br /> hill 7a//eG� <br /> (� hs (� 3� <br /> All <br /> Plan revision required? ❑ Yes Wo <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />