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I ° 3a W5Ccn5i,q /TtOCL <br /> Wisconsin Department of Industry, PRIVATE SEWAGE�SYSTEM County. <br /> Labor and Human Relations <br /> Safety and Buildings Division INSPECTION REPORT ('note:- <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No : <br /> igSsil <br /> Permit Holder's Nam 0 City El village Town of: State Plan ID No.: �� <br /> M; J)es a r� (J.A'lian . <br /> CST BM Elev.: Insp.BM Elev.: BM Description: Parcel T x No <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic W! iwr Benchmark , 1 111& w /aQ <br /> — <br /> Dosi ng <br /> Aeration Bldg-Sewer Ll1d5 1?4 <br /> Holding St/Ht Inlet y,0& 1 ,79. 35 <br /> TANK SETBACK INFORMATION St/Ht Outlet LAIR g7rr3 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic 7/001 gC:Q5S NA Dt Bottom <br /> Dosing NA Header/Man. ,j, 3 <br /> Aeration NA Dist. Pipe 16 , 6y <br /> Holding Bot.System , 95�y <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> E <br /> del Number GPM <br /> Lift Lriction System TDH Ft <br /> ead <br /> Forcemain Length Dia. H Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width I Length f No Of TrenchesPIT No Of Pits [Inside Dia. liquid Depth <br /> DIMENSION DI N I <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION TypeO n. !4)f jjq 11L/ <br /> Moe Number: <br /> System: OR <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold L/yl Distribution Pipe s) xHole Size xHole Spacing Vent To Airintake <br /> Length � Dia _(_ Length Dia. 7 Spacing r <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 /> Plan revision required? ❑ Yes ❑ No q ^ <br /> Use other side for additional information. g /3 <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />