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rR�1rM �. \J1. �7• G WWP%%J 1 G 1 r\L r%• 1Wr L.•. • %J I%. • L M%R MUF"Uu %,UUIIly <br />Nvis'lI6��Iw <br />(POwr$) Property Address: <br />Department of Commerce INSPECTION REPORT <br />Safety and Buildings Division (ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />Personal information you nrovide may be used for secondary purposes f Privacy Law. s. 15.04 (l)(m) I <br />Permit Hold r' <br />,���7777 <br />Name: <br />II %� ! .. t �,�� <br />�,1��(� <br />Town of: <br />CST BM Elev: <br />/00-00 <br />Dosing <br />Insp BM Elev: <br />6AA4 r -e <br />BM Description: <br />sPEA) 3' <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER CAPACITY <br />Septic <br />6XA I.0 7,50 6A1.441.) <br />Dosing <br />yr 5ov G4u k) <br />Aeration <br />>W <br />Holding <br />18' <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />VENTTOROAD <br />AIR INTAKE <br />Lift 1. q6 <br />Septic <br />>W <br />WIA <br />18' <br />— <br />NA <br />Dosing <br />Waters <br />CELL TO <br />> 550 <br />> SD <br />NA <br />Aeration <br />NA <br />Holding <br />St / Ht Outlet <br />PUMP / SIPHON INFORMATION <br />Manufacturer <br />Z ri. 4 R— <br />Demand <br />7 S50 GPM <br />Model Number <br />1,5z <br />Lift 1. q6 <br />Fr. Loss ), 4 <br />1 Head --- <br />TDH > //.3 <br />Force main <br />Length 75' <br />1 Dia <br />Dist/Well <br />DISPERSAL CELL INFORMATION <br />DIMENSIONS <br />Width <br />Length ,5O <br />No of Cells .2. <br />SETBACK <br />P I L <br />Bldg <br />well <br />OHWM of Nav <br />INFORMATION <br />Waters <br />CELL TO <br />> 550 <br />> SD <br />*/A <br />;. 2.00' <br />DISTRIBUTION SYSTEM <br />ELEVATION DATA <br />Sanitary Permit No: <br />State Plan Transaction ID#: <br />Parcel Tax No: <br />0;)4 — alnS—o i " c5[) <br />Type of System <br />LEACHING <br />CHAMBER <br />Manufacturer: <br />W4Ve'14urla I <br />Zn-geo>jd <br />wl /.-ifT <br />Model Number: <br />Length Dia <br />Length Dia Spac <br />Topsoil <br />Spacing <br />GrYes ❑ No <br />St / Ht Outlet <br />M.-- •SystemElevation <br />Type of System <br />LEACHING <br />CHAMBER <br />Manufacturer: <br />W4Ve'14urla I <br />Zn-geo>jd <br />wl /.-ifT <br />Model Number: <br />X Pressure Systems Only <br />Header I Manifold <br />Distribution Pipe(s) <br />X Hole Size <br />X Hole <br />Observation Pipes <br />Length Dia <br />Length Dia Spac <br />Topsoil <br />Spacing <br />GrYes ❑ No <br />SOIL COVER <br />Depth Over <br />Depth Over <br />Depth of <br />Seeded/ Sodded <br />Mulched <br />Cell Center <br />Cell Edges <br />Topsoil <br />❑ Yes 13No <br />13Yes 11No <br />COMMENTS: (Include code discrepancies, persons present, etc.) <br />Components Not Inspected <br />w' Permit Posted Cover Material-rYPAP, <br />m"' Warning labels on manhole covers w/locks <br />®' Schedule 40 Vent Material <br />e Effluent Filter installed Model �ISaU MFR. <br />Plan revision required?❑ Yes ❑ No Z 7 p <br />Use other side for additional information Date POInspector's Signa Cert No <br />Bureau of Field Operations, PO Box 7302, Madison, WI 53701-7302 SBD -6710r(3/101 ) <br />