HomeMy WebLinkAbout032-1030-50-150 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide maybe used for secondary po,poses Fnva�y Law, s.15 04 (1 )(m)]
Permit Holders Name City Village Township
Jerry & Shirley Aul I TOWN OF SOMERSET
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
PIL
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
MDH
Tiff
Friction Loss
System Head
TDH Ft
F fee ,in
L, , th
Dia�
Dist. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
STATION
BS
HI
FS
ELEV.
Benchmark
Alt BM
Bldg Sewer
SUHt Inlet
SUM Outlet
Dt Inlet
Of Bottom
Header/Man.
Dist. Pipe
Bet. System
Final Grade
St Cover
BED[TRENCH
DIMENSIONS
Width
Length
I
No� Of Trenches
PIT DIMENSIONS
INo Of Pits
Inside Dia
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
IPJL 71K�WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
DISTRIBUTION SYSTEM
readerlivaniffold
Distribution
x Hole Sr,o
Hole Spacing
Vent to A,
11-ength_
P re(s)
11-ength
ix
Di
Dia Spec ... g_
SOIL COVER x Pressure Svstems OnIv xx Mound Or At -Grade Svstems Oniv
Depth Over
Depth Over
Depth of
xx Seeded/Sodded
Mu lobed
IBedfTrench Center
I Bechrrench Edges
Topsoil
I F-1 Yoe El No
1�
E] Yes Ll No
COMMENTS: (include code discrepancies, persons present, etc) Inspection #1.
Location: 657 LAKESIDE LN
1.) Alt BM Description -
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? Yes 7� No
Use other side for additional information.
SBD-6710 (R 3,W) Date Insepcters Signature
Inspection #2.
Ceo No