HomeMy WebLinkAbout030-2157-11-000Wsconsin 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 [Pnvacy Law, s 15 04 (1)(mul
IANK INFORMATION
MAN
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
7 DH
Friction Loss
System Head
TO Ft
F",e,L,',ri
Len, th
I Dia
I [),at to Well
Z)UIL At5ZiLJKI' I [ON SYSTEM
ELEVATION DATA
BEDITIRENCH
DIMENSIONS
Width
Length
I
No Of Trenches
I
PIT DIMENSIONS
No Of Pits
Inside Dil
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
JP/L
JBLDG
IWELL
LAKE/STRETMT
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
I
I
I
Model Number
VIQ I MIDV 1 1WIN 0 T a I r1i
theader/Mariffold
IlDistribution
Hole Sa,e
Hole Spacing
Vent to Air Intake
iLength_
Pipe(s)
Ix
I
Da_
iLength_ Dja Spacing_
SOIL COVER x Presnura q��t.m� nrih, — mo—A n' Q ..— n�
Depth Over
Depth Over
Depth of
Seeded'Sodded
Mulched
B.di Center
I
BectTrench Edges
I
Topsoi
1�
-]
I"
Yes No
El Yes
COMMENTS: (Include code discrepancies. persons present, etc) Inspection #1.
Location: 407 134TH AVE
1 ) Alt BM Description
2 ) Bldg sewer length
- amount of cover
Plan revision Required9 [_] Yes El No
Use other side for additional information.
SBD-6710 R 3/97)
Inspection #2
- � � L--- - L
Dale Insepctor's Signature Can No