HomeMy WebLinkAbout026-1064-00-120Wisconsin 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, s 15 04 (1)(m)]
Permit Holdefs Name City Village Township
Daniel J. and John E. Dahlberg I TOWN OF RICHMOND
CST BM Elev Ilinsin BM Elev IBM Description
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANKTO
PIL
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Litt
Friction Loss
System Head
TDH Ft
Forcemain
Length
Dia.
Dist to Well
SOIL ABSORPTION SYSTEM
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg Sewer
St/Ht Inlet
SVHt Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BED/TRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No Of Pits
Inside Dia
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
Type Of System:
P/L
BLDG
WELL
LAKEISTREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold
Distribution
x Hole Size
x Hale Spacing
Vent to Air Intake
Pipe(s)
Length Dia
Length Dia Spacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
xx Mulched
Bedlrrench Center
BedFrrench
Edges
Topsoil
r= yes
1:1 No
El Yes
� No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1112 145TH AVE
1.) Alt BM Description =
2 ) Bldg sewer length =
- amount of cover =
Plan revision Required? 0 Yes No 1 Use other side for additional information I _ __ Ll
SBO-6710 (R.3/97) Date Insepctors Signature Can No