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Wiscv^�in Department of Commerce PRIVATESE AGESYSTEM Coun <br /> Safety anis Buildings Division INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal Information you provice may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. ,5 �tv <br /> Per .t H Ider's NarrAe: ❑ City El Village T n of: State Pan ID No.: <br /> S 8M E e ` sp.BM :z BMD c"p}tpny� ' Parcel Tax No.: � / 6' <br /> rl V'�'r� <br /> TANK INFORMATION EL VATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> eptic a 3 0`1Y' <br /> Dosing �60 <br /> Aeration Bldg.Sewer <br /> Holding w ttr� t7U�' St/ Inlet �? ; 7 S. S <br /> TANK SET INFORMATI St/ Outlet �AD � <br /> TANKTO P/L WELL BLDG. Veintake ROAD 40t Inleto?.rt�Q� 7, 7 <br /> 1 <br /> Air Septic NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding I 3-j Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand q <br /> Model Number GPM �—,�_j r"; r736 <br /> TDH Lift Loction System TDH Ft <br /> Head <br /> Forcemain Length Dia. Dist.To Well TD p `M f �/ a <br /> SOIL ABSORPTION SYSTEM <br /> RED/TRENCH Width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION TypeO Mo a Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold DistributionPipe(s) x Hole Size x Hole 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/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies persons present,etc.) Pre rn,,, i P65 <br /> Plan revision required? ❑ Yes o ;/ 5 <br /> Use other side for additional inform6tion. 1111131 F_ Kai r)�— I7 <br /> SBD-6710(R.3/97) Date Ins ector's Signature Cert No <br />