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__)— I- 1�3, ) : 5J <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: � � <br /> Labor and Human Relations <br /> Safety and8uildings Division INSPECTION REPORT bu,rp,_,t�7- <br /> (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION IIS_�5 <br /> Permit Holder's Name:� ❑ City L] Village .Town of: State Plan ID No.: <br /> L�uu d r e a <br /> CST BM Elev.: Insp-BM Elev-: BM Description: Parcel Tax No.: <br /> —oL—`�C50 <br /> - <br /> - — <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic go BenchmarkDosing <br /> Aeration Bldg.Sewer �zj 96.86 <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic �S -7 .2S NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot. System '7 AL +lQ ' <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM I 6 < <br /> TDH Lift <br /> Frictossion System TDH Ft <br /> Forcemain Length Dia. Head <br /> Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No.Of Trenches PIT No.Of Pits Inside Dia Liquid Depth <br /> DIMENSIONS DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type Of �r ''// r CHAMBER Model Number: <br /> System: gj�b sd� 7� �sd A)A- OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: ,p` nclude code discrepancies,persons present,etc.) <br /> c g <br /> Ted ri- de <br /> Plan revision required? ❑ Yes r 1 o <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No <br />