HomeMy WebLinkAbout020-1481-09-170Wisconsin Department of Commerce
PRIVATE SEWAGE SYSTEM
County St. Croix
Safety and Building Division
INSPECTION REPORT
Sanitary Permit No
GENERAL INFORMATION
(ATTACH TO PERMIT)
633334
State Plan ID No
Personal information you provide may be used for secondary
purposes [Pnvacy Law s 15 041L(mQ
Penmt Holder's Name
Ryan 8 Jamie Johnson
City Village Township
I 1
Parcel Tax No
TOWN OF HUDSON
020-1481-09-170
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Loss
SOIL ABSORPTION SYSTEM
ELEVATION DATA
Inlet
BS
BEDITRENCH
DIMENSIONS
Width
Length
No Of Trenches
PIT DIMENSIONS
No Of Pits
Inside DIa
Llgold Depth
SETBACK
INFORMATION
SYSTEM TO
PIL
IBLDG
WELL
LAKEISTREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
UW IKI OU IIVIV JTSItM
Header'Mandold
Distribution
x Hole Size
x Hole Spacing
Vent to Air Intake
Pipelsl
ngth ia LeD
Length Dia Spacing
SCAL GUVtK x Pressure Svstems Only xx Mnund Or A6Orade Rvsfnme nnlv
Depth Over
Depth Over
ra Depth of
Seeded/Sodded
xrrench
xx Mulched
BedrCenter
BedrTrench Edges
Topsoil
n Yes E No
I --I Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1 Inspection #2
Location: 1070 AUTUMN OAK LN
1) Alt BM Description =
2) Bldg sewer length =
- amount of cover =
Plan revision Required? _ Yes — No I
Use other side for additional Information ��- L�
SBD-6710 (R 31971 Date Insepctors Signature Cert No