HomeMy WebLinkAbout026-1309-21-000Wisconsin Department of Commerce
PRIVATE SEWAGE SYSTEM
St. Croix
Safety and Building Division
INSPECTION REPORT
Sanitary Permit No
GENERAL INFORMATION
(ATTACH TO PERMIT)
633858
State Plan ID No
Personal information you drici may be used for secondary
purposes [Privacy Law s 15 04 (1)(m)]
PE�tldj "s Name
Cjr� Village Township
Parcel Tax No
I rivestments LLC
I TOWN OF RICHMOND �
026-1309-21-000
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANKTO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMPISIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
I
7 DH
Lift
F:
Friction Loss
System Head JOH
Ft
F to. -am
L. : th
Dia.
—
Dist to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
STATION
BS
H I
FS
FLEV.
Benchmark
Alt. BM
Bldg Sewer
SUHt Inlet
SUIT: Outlet
Dt Inlet
Dt Bottom
Header/Man
Dist Pipe
Bot System
Final Grade
St Cover
BEDrrRENCH
DIMENSIONS
Width
Length
I
IT DIMENSIONS
No Of Pits
uid Depth
SETBACK
INFORMATION
SYSTEM TO
1P-1-L.-
BLDG
I
WEE
I
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
F 7-7
Model Number
1015 1 HIBUI I IUN SY5 FFM
Headerlivanifold
ID,stnitupon
Hole Sure
Hole Spacing
I
If
1�
I
Length_ Do _Iplpeis)_
Length Dia Spacing _
501L L;l x Pressure Svatems Oniv wit Marand Or At-Gr.d. S�t.nri Cniv
Depth Over
Depth Over
Depth of
Seeded/Sodded
Mulched
Bed1firench Cent.,
BedfTrench Edges
Topsoil
Yes [:] No
Y
COMMENTS: (include code discrepancies, persons present, etc.) Inspection #1 Inspection #2:
Location: 1479 166TH AVE
1 ) Alt BM Description -
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? — Yes Ll No
Use other side for additional information,
SBD-6710 (R 3/97) Date inselectai's Signature Can No