HomeMy WebLinkAbout022-1073-80-500Wisconsin 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 tPnvacy Law, s 15 04 111(ml]
Permit Holder's Name City Village Township
James & Dawn Hauschild TOWN OF KINNICKINNIC
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
Vent to Au Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Fdid" , Length Dia Dist to t')ell
SOIL ABSORPTION SYSTEM
ELEVATION DATA
STATION
BS
HI
FS
ELEV
Benchmark
Alt BM
Bldg Sewer
SHHt Inlet
SVHt Outlet
Dt Inlet
Dt Bottom
Header/Man
Dist Pipe
Bot System
Final Grade
St Cover
BEDfTRENCH
DIMENSIONS
Width
Length
No OI Trenches
PIT DIMENSIONS
No Cf Pits
Inside Dia
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
P/L
BLDG
JVVELL
LAKEISTREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
UIJ I hi I IVIN J Y, I
HeaderWamfold
Distribution
x HOIe Size
x Hole Spacing
Vent to Air Intake
Pipe(si
Length Dia
Length Ds Spacing
JVIL (.;i x Pressure Svstems nnty v: MnunH nr At.nr.ne su.t— nnly
Depth Over
Depth Over
vx Depth of
"psotl
xx Seeded;Sodded
vx Mulched
BedlTrench Center
BedrTrench Edges
To
J Yes No
Yes NO
COMMENTS: (Include code discrepencies persons present, etc) Inspection #t Inspection #2
Location: No Address Available
1 ) All BM Description =
2 1 Bldg sewer length =
- amount of cover =
Plan revision Required? Yes No I
Use other side for additional Information
SBD-6710 (R 3/97) Date Insepctors Signature
I�
Can No