HomeMy WebLinkAbout026-1306-00-031Wisconsin 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, a 15 04 (1)(m)]
Permit Holi Name
City Village Township
Joshua and Rebecca Moore
I TOWN OF RICHMOND
CST BM Elev
I Insia. BM Elev
BM Description
TANK INFORMATION
ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANKTO
PIL
WELL
BLDG
Vent to Air Intake
ROAD
Septic
Dosing
7
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
DH
Lift
Friction Loss
System Head
TDH Ft
F ... main
Lian th
Dia.
Dist to Well
SOIL ABSORPTION SYSTEM
County: St. Croix
Sanitary Permit No:
633352
State Plan ID No
Parcel Tax No:
026-1306-00-031
Sectionrrown/Range/Map No
19.30.18.1638
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg. Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Of Bottom
Header]Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BEDrrRENCH
DIMENSIONS
Width
Length
No. 0 Trenches
PIT DIMENSIONS
No. Of Pits
Inside Die
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
Type Of System
IP/L
JBLDG
IWELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold
Distribution
x Hole Size
Hole Spacing
Vent to Air Intake
il-ength
Pipe(s)
Dia_
Length Dia Spacing_
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
Depth of
Seede&Soddecl
Mulched
Bed/Trench Center
Bedr-rench
Edges
To psoil
Yes
[:] No
Yes
[2 No
COMMENTS: (include code discrepancies, persons present, etc.) Inspection #1:
Location: 966 150TH AVE
1.) Alt BM Description -
2.) Bldg sewer length =
- amount of cover =
Inspection #2:
Plan revision Required? E] Yes E] No
Use other side for additional information.
SBD-671 0 (R.3)97) Date Inseirctors Signature Cert. No