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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun . <br /> Safety and Buildings Division INSPECTION REPORT ECliW6 <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be ed or secondary purposes[Privacy Law,s.15.04(1)(m)). S��O <br /> Permit Holder's Nam . ❑ City ❑ Village <br /> 0Bown of: State Plan ID No.: <br /> Cl <br /> ta re <br /> CST BM Elev.: Insp.BM Elev.: I BM Description: Parcet Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic7S0 Benchmark . S <br /> Dosing cj Soo <br /> Aeration Bldg.Sewer ®- 9 <br /> Holding I St/Ht Inlet 11A41 916 &7 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. vent to, ROAD Dt Inlet �— <br /> Septic >�S SAir Intaeas >S — NA Dt Bottom <br /> Dosing > o � NA Header/Man. S ' ,0(a <br /> Aeration NA Dist. Pipe ,0 <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade Q� <br /> Manufacturer .D�emmand ry <br /> Model Number t7GP``M <br /> TDH Lift Friction ; Systems TDH ' ,/ft <br /> Forcemain Length�� Dia. H,�2 n I Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCHWidth i Length ., No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIM I N 11 DIMENSIONS <br /> SETBACK SYSTEM TO P!L BLDG WELL LAKE/STREAM <br /> LEACHING Manufacturer: <br /> INFORMATION TypeO Cp i CHAMBER Mode Number: <br /> System: 1/ >/, �d 7x200 OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Maf m�foId it Distribution Pipe(s) )i t x Hole Size x Hole Spacing Vent T, Air Intake <br /> Length lJ Dia. I Length a2 Dia. Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Ofxx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No El Yes ❑ No <br /> COMMENTS: (Incl a co a d' c e I Hues,persons present,etc.) rJ11/1e_C,/0#" <br /> U — l � 2-AkIl <br /> A lN'Q r1�a <br /> f"141 e �i�4el W///y cFcgle r <br /> vo_ww/,�rel X4�ne_o �/As tzAk <br /> S� Y�4tnkers f/r f"�� �/ r <br /> Pla evi srequired ❑ Yes 1Jo <br /> Use otherr side for additional information. <br /> SBD-6710(R.3/97) Date Inspector's5ignature Cert No <br />