HomeMy WebLinkAbout020-1452-09-000 (2)Wisconsin Department of Commerce
Safety and Building Division
GENERAL INFORMATION
Personal information you provide may be used for secondary purposes
CHARLEY STEPHENSON
,ST BM Elev, linsp BM Elev
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
[Privacy Law, s 15,04 (1)(m)]
TYPE
MANUFACTURER
CAPACITY
Septic
1 f
•�'
IO O
�'
' 2c, l
Aeration
Holding
TANK SETBACK INFORMATION j(o" m S(rruns) 0"I
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model
umber
TDH
Ift
notion Los
S stem He d
T Ft
Force in
Length
Dia
Di to Well
SOIL ABSORPTION SYSTEM
TOWN OF HUDSON
ELEVATION DATA
STATION
BS
HI
FS
ELEV.
Benchmark
-7
Alt. BM
Bldg. Sewer
cxl
St/Ht Inlet
SUHt Outlet
Inlet
rOf
pm
U0. tAQ
%.tJ
ito
it,
(1�•82
Header/Man.
8.�
112.72
Dist Plpe
G IH
Tl
Z
2. 7
z
But System
TI
y,
"I/. 7Z
41. 47-
Final Grade
S, Lf
1!;•JZ
z
St Cover
Gx;
G;S +ZA (1Ar A.-rc
BED/TRENCH
DIMENSIONS
Width
3 x
Length
Cj tJr
// _ 1i
No Of Trenches
�/ ' iK. Lj
/BBLLDG
PIT DIMENSIONS
No Of Pits
Inside D
uid Depth
SETBACK
INFORMATION
SYSTEM TO
P/L
WELL
LAKEISTREAM
LEACHING
CHAMBEROR
UNIT
IMarufacturer
kC( 6r
Type Of System
Ty
(raH
/� r
7/ .
I \ CO t
Model Numher
DISTRIBUTION SYSTEM
Header/Manifold r
) N r
Length Dia
Distribution
P Pe(s)
Length Dia Spacing
x Hole Size
x Hole Spacing
Vent to Air Intake
4 i f V1
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only
Depth Over t
Bedarench Center 2
2, —✓
Depth Over 1 x
Bedrrrench Edges / Z
xx Depth of
To
xx Seeded/Soddetl
xx Mulched
-
[:I Yes No
Yes No
COMMENTS: (Ind ude code discrepancies, persons present, etc.) Inspection 41 Inspection 42
Location: 817 DOVE CT f _ -• V'1° V1 15 00 V't.e5 ,Jl �nj
1.) Alt BM Description =, �UVL 6 tK (over
2 ) Bldg sewer length = I I I
-amount of cover =r—'x%5•'Y-�
Plan therm Required? [ Yes Nop � % Use other side for additional infonnati
Date Ir ct s Si nature Cert No
SBDb710 (R 3/97)