HomeMy WebLinkAbout040-1310-00-022 (3)Wisconsin 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, a 15 04 (1)(m)]
Permit Holders Name City Village Township
EnC & Shannon Cook I TOWN OF TROY
TST Did i I B&I Description
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANKTO
P/L
WELL
BLDG
Vent to A, Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
I
UP]
Lt
Friction Loss
System Head
TDH —Ft
F.r..-.,n
L,, th
Dia.
Dist. to Well
SOIL ABSORPTION SYSTEM
STATION
BS
H I
FS
Ei
Benchmark
Alt. BM
Bldg, Sewer
St/Hit Inlet
St/Ht Outlet
Ot Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot System
Final Grade
St Cover
BEDITRENCH
DIMENSIONS
Width
Length
I
No Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
JPIL
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
DISTRIBUTION SYSTEM
HeaderlManifold
Distributor
Hole Size
Hole Spacing
Vent to Air Intake
iLength_Dia__
Pite(s)
ix
1�
Length Dm Spacing—
SOIL COVER x Pressure Svsterns OnIv xx Mound Or At -Grade Svstems OnIv
Depth Over
Depth Over
Depth of
SeededlSodded
M clothed
Becirfrench Center
Bed/Trench Edges
iTopsoil
I- L I Yes El No
1�
r� Y
COMMENTS: (Include core discrepancies, persons present, etc )
Location: 313 MEADOW RIDGE CT
1.) Alt BM Descirption
2T Bldg sewer length
- amount of cover
Plan revision Required? Yes — No
Use other side for additional information.
Date
SBD-6710 (R.3/97)
Inspection 41.
Insepotor's Signature
Inspection #2
Cert No