Laserfiche WebLink
9- X `3 <br /> Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: <br /> Labor and Human Relations INSPECTION REPORT � kF43ET <br /> Safety and Bu;lding5 Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION ) <br /> Per 't Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: <br /> CST BM Elev.: Insp.B Elev.: BM Description: Parcel Tax No.: <br /> v sem[, I d-33x7- 05-ZCC 10 <br /> TANK INFORMATION El EVATI N DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic /?5() Benchmark 85 �OD <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet G,( y <br /> TANK SETBACK INFORMATION St/Ht Outlet �i,�P x(,.25 <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake <br /> Septic L/Q NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe (/ %,6d� <br /> Holding Bot.System 7,6� f'5-,(p <br /> PUMP/ SIPHON INFORMATION Final Grade zjs �Q Q <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Lriction System I-ead TDH Ft <br /> Forcemain Length Dia. I Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width t Len th r No.Of Trenches PIT No.Of Pits nside Dia. Liquid Depth <br /> DIMEN I N l DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK CHAMBER <br /> [ / t model Number: <br /> INFORMATION Type Of <br /> System: l/ �D Sd /''� OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold UU``r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Jx Dia Lengthy I Dia L Spacing ,�{1'I✓ D o0?a <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 ❑ No3 <br /> Use other side for additional information. <br /> SBD-6710(R 05/91) Date Inspe r Signature Cert.No. <br />