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`z3 IZ' ate <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> k / <br /> Labor and Human Relations INSPECTION REPORT i l <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No : <br /> GENERAL INFORMATION <br /> Permito�lder's Name: (� ❑ City ❑ Village Town of: State Plan ID No �I <br /> �J(J - /J-II— <br /> CST BM Elev.: Insp.BM Elev.: BM Description: Parcel Tax No.: <br /> /f�7i�lh LlIlie Oak C6- � 143, — <br /> TANK <br /> 3, —TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic S 000 Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer 717 L <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet D <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic >/6L K25- 0 n/f} NA Dt Bottom _ — <br /> Dosing NA Header/Man. ,$f 9�10 <br /> Aeration NA Dist. Pipe ,zL 9 .O <br /> Holding Bot.System gg� <br /> PUMP/ SIPHON INFORMATION Final Grade <br /> dj <br /> Manufacturer Demand �1 1/ / <br /> Model Number GPM b�r1 �l�Rr ^d�< <br /> TDH Lift Lriction System TDH Ft �� �jS e �'a� 3• rp <br /> Forcemain Length Dia. Fi Dist Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width length/ 2, No.Of nches PIT No.O4 Pits Inside Dia. Liquid Depth <br /> DIMENSIONS /-Z� (�/ DIMENSIONS <br /> SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM <br /> LEACHING Manufacturer: <br /> INFORMATION TypeO pp / CHAMBER Mode Number: <br /> System: �� OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold >y Distribution Pipe(s) , /i x Hole Size x Hole Spacing Vent To Air Intake <br /> Length _4—/ Dia. /7' Length -J/ 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/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Well - wee+ re (II (e <br /> Plan revision required? ❑ Yes SA No <br /> Use other side for additional inform tion. <br /> SBD-6710(R 05/91) Date Ins ector's Signature Cert.No. <br />