HomeMy WebLinkAbout040-1326-21-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information You provide may he used for secondary purposes [Privacy Law a 15.04 (1)(m)]
Perm it Hcoer's Nam. City VIllage Township
DCC1 Investments LLC I TOWN OF TROY
CST HIM Flay I Insp BM Elev —]79-K�tion
I ANK INFUKMA I IUN
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG,
Vent to A, Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
I
TDIT
Lift
Fricion Loss
System Head
TDH Ft
Forcemain
I Length
I Dia.
I 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
Bot. System
Final Grade
St Cover
BEDrrRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No Of Pits
Inside D,a
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
PIL
�WELL
LAKE/STREAM
I LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
DISTRIBUTION SYSTEM
Header/Manifold
IDearbution
Hole Size
Hole Spacing
11-ength
Pipets)
Dia_
I Length_ Dia_ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At4rade Systems Only
Depth Over
Depth Over
Depth of
Seededl
Mulched
BedfTrench Center
BedlTrench Edges
To
im psod
1:1 Yes L I No
im F-1 Yes
COMMENTS: (include code discrepancies, persons present, etc.)
Liocation; 377 MEADOW VALLEY TRL
1�) Alt BM Desorption -
2.) Bldg sewer length -
- amount of cover -
Plan revision Required? E] Yes Lj No
Use other side for additional information
Inspection #1:
SBD-6710 (R 3/97) Date linseirctoes Signature
Inspection #2:
-] �
Cerl No.