HomeMy WebLinkAbout022-1003-55-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal Information you provide may be used for secondary purposes [Privacy Law, s 15 D4 111mi
Permit Holder's Name City Village Township
Elizabeth C. Weir & Marjorie Weir I TOWN OF KINNICKINNIC
CST BM Elev linsp BM Elev IBM Description
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P,'L
WELL
BLDG
'Dent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemam Length Dia Dist to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
STATION
BS
HI
FS
ELEV
Benchmark
Alt BM
Bldg Sewer
St/Ht Inlet
St'Ht Outlet
Dt Inlet
Dt Bottom
Header/Man
Dist Pipe
Bat System
Final Grade
St Cover
BED/TRENCH
Width
Length
No Of Trenches
PIT DIMENSIONS
No Of Pits
Inside Dia
Liquid Depth
DIMENSIONS
SETBACK
SYSTEM TO
P/L
JBLDG
JVVELL
LAKE/STREAM
I LEACHING
Manufacturer
INFORMATION
CHAMBER OR
Type Of System
Model Number
UNIT
UIJ I KIkiU I IUN SYSTEM
Header/Manifold
IDistribution
itHole Sae
z Hole Spacing
Vent to Air Intake
Pipers)
Length Dia
Length Dia Spacing
SUIL UUVhK X Pressure Systems Only xx Mrnmd Or At_Rrade Rvstams (lnly
Depth Over
Depth Over
Depth of
xx SeedediSotldetl
xx Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
❑ Yes _, No
G Yes _ No
COMMENTS: (Include code discrepencies, persons present. etc) Inspection #1
Location: 1332 CTY RD N
t ) Alt BM Description =
2) Bldg sewer length =
- amount of cover =
Inspection #2
Plan revision Required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 IR 1971 Date Insepctor's Signature Can No