HomeMy WebLinkAbout028-1031-90-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix
Safety and Building Division INSPECTION REPORT Sanitary Permit No
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No 633875
Personal inforroation you provide may be used for secondary puToses Lnvacy Law, s 15 04 (1)(m)] 072101725-C
Permit Holders Name City Village Township Parcel T.� No.
Charles J. Langer I TOWN OF RUSH RIVER] 028-1031-90-000
ZST BM Elev Insp BM Elev BM Description Seclum/Lown/Rainge/Map No
1 1 25.28.17.199
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Hcdmg
TANK SETBACK INFORMATION
TANKTO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
I
Aeration
Holding
PUMPISIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
I'mc0ion Loss
System Head
TDH Ft
Forcermain
I Lem� th
Dia..
D".
[Dist to Well
SOIL ABSORPTION SYSTEM
STATION
BS
Hl
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
BEDITRENCH
Width
Length
No 0 Trenches
PIT DIMENSIONS
No. Of Pits
Insid Dia.
Liquid Depth
DIMENSIONS
I
I
SETBACK
SYSTEM TO
P/L
IBLDG
LAKEISTREAM
LEACHING
Manufacturer
INFORMATION
IWELL
CHIA BER OR
UNIT
T—ype Of System
Model Number
UISTRI13UTION SYSTEM
Header/Manifold
Distribution i
X Hole Size
Hole Spacing
Vent to
Pipe(s) i
1X
I
Length_ D a
Length_ Dia_ Spacmg_
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
Depth of
Seeded/&added
Mulched
Bed/-rrnch Center
BedfTench Edges
To
1� psoil
1:1 Yes 7] No
E Yes
COMMENTS: (include code discremenoies, persons present, etc)
Location: 2017 18TH AVE
1 1 Alt BM Description
2.) Bldg sewer length
- amount of cover
Plan revision Required9 Yes No
Use other side for additional information.
Date
SBD-6710 (R 3/97)
Inspection #1:
Insepctor's Signature
Inspection #2.
Cert No