HomeMy WebLinkAbout026-1304-13-000AIsconsin Department cf Commerce
PRIVATE SEWAGE SYSTEM
-.runt, St. Croix
Safat� and Butting Division
INSPECTION REPORT
Sanidr� Permit No
GENERAL INFORMATION
(ATTACH TO PERMIT)
633861
State Plan ID Nc
Personal information you provide may be used for secondary purposes (Privacy Law a 15 04 ( 1)(m)]
Permit Holders Name
Bill Kieckhoefer
City Village Township
I
Parcel T., We
TOWN 0
026-1304-13-000
-ST BM Elev linsp BM Elev
IBM Dvs�irigtion
TANK INFORMATION
CAPACITY
TANK SETBACK INFORMATION
TANK TO
PIL
WELL
BLDG
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDIT 11-ift 11'richon Loss S I Ft
Forcernam Length I Dia Dist to vV.11
54JIL A13SORPTION SYSTEM
ELEVATION DATA
SUHt Outlet
Dt Inlet
Dt Bottom
Header Man
Dist Pipe
Grade
HI
BEDITRENCH
DIMENSIONS
Wain
Length
I
No Of Trenches
I
I
PIT DIMENSIONS
I
ING Of pit�
Inside Dr.
I
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
��ELL
JILAKE/STR
LEACHING
CHAMBER OR
UNII
IManufacturer
I
Type Of System
. . .
I
I I
I
I Model Number
LJIZ' I KItJLI I ILJIN Z)Yb I LM
H..d.,/Mamfold
D!stribuhon
Hole Siae
Hole Spacing
Vent to At
P pe(s)
li-ength_
Dia_
Dia_ Spacing
Z)UIL UUVtK x Pressure Systems Odle ity Monind Or At-rrnrin �v�frima nnlv
Depth Over
Depth :),ar
Depth of
Seeded Sodded
Bed Trench Center
Bedrr-rren�h Edges
TPps.,l
I.Mulched
Yes No
Yes
COMMENTS: (Include code discrepancies, persons present, etc Inspection #1 Inspection #2
Location: 1625 92ND ST
I Alt BM Description
2 Bldg sewer length
- amount of cover
Plan revision Required? j Yes F] No
Use other side for additional information
SBD-6710 (R 3/97) Date Insepctor's Signature
Can No