Laserfiche WebLink
wisconsln-DepartmentofIndustry, PRIVATE SEWAGE SYSTEM County: <br /> Laborand Human Relations INSPECTION REPORT <br /> Safetety,and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary ermitNo.: <br /> GENERAL INFORMATION ate' , '& <br /> Permit Holder's Name: ❑ City Villa Town of: State Pla 1 ID No.: <br /> CST BM Elev.: Insp.BM Elev.: BM Description: Parcel Ta No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS FS ELEV. <br /> Septic Benchmark 6, 5 <br /> Dosing <br /> Aeration Bldg.Sewer Q� <br /> Holding St/Ht Inlet 8r � <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet <br /> Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe 3j9 <br /> Holding Bot. System q.? <br /> PUMP/SIPHON INFORMATION Final Grade aa� <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction SFystem ead TDH Ft Loss <br /> Forcemain Length Dia. Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMEN I NS DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> CHAMBER <br /> INFORMATION 7ype0 Model Number. <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) x Hole Sizex Hol Spacing Vent To Air Intake <br /> Length 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/So ded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present, etc.) <br /> Plan revision requiredYes ElNo <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No <br />