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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: /1 <br /> Labor and Human Relations INSPECTION REPORT <br /> Safety and Buildings Division <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No : <br /> Permit Holder's Name: t �� ❑ City El Village [] Town of: State Plan ID No.: <br /> Z_-, V <br /> CST BM Elev.: Insp.BM Elev.: BM Des cn ion: Parcel Tax No.: <br /> ¢ 1,, g,4,176<4drogeae <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic j0 Benchmark ,S$ 'Qd <br /> Dosing <br /> Aeration Bldg.Sewer <br /> 6&61 C17 <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet �Q S <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic `J ?5 7 �� �.— NA Dt Bottom -- <br /> Dosing NA Header/Man. <br /> i <br /> Aeration NA Dist. Pipe �- • <br /> Holding Bot.System � �� f,7r <br /> PUMP/SIPHON INFORMATION Final Grade j 8(� �0 �9' <br /> Manufacturer Demand <br /> Model Number GPM 7b S�a�O— '4m- AV-17 <br /> TDH Lift Friction System TDH Ft oss �w�urc D� <br /> ead <br /> Forcemain Length Dia. H Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Lengty No.Of Trenc s PIT No Of Pits Inside Dia. Liquid Depth <br /> DIMEN I INZ szo DIMENSIONS <br /> SETBACK <br /> SYSTEM P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION IypeU 8= / , CHAMBER Moe Number: <br /> System: �.�'.S 5 Jr0 NA-, OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe((ss)/ � (+ /_� z Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia L� Length ( Dia. Spacing V <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,pers ,etc.)o spresent <br /> gym- u,3$ s <br /> Plan revision required ❑ Yes Jq No <br /> Use other side for additional inforrryatItin. 41WEI <br /> SBD-6710(R 05/91) Date I Inspector's Signature Cert.No. <br />