HomeMy WebLinkAbout020-1414-60-000 (2)Wsconsm Department of Commerce
Safety and Building Division
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s 15 04 (1)(m)]
John D. and Cindy M. Baker City wuage I,wnshipTOWN OF HUDSON
CST BM Elev jInsp BM Elev IBM Descnoton '1
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
CC
Aeration
Holding
TANK SETBACK INFORMATION
PUMP/SIPHON INFORMATION
ELEVATION DATA
STATION
FS
ELEV.
Benchmark
11
(DD, a"
Alt BMBldg
Sewer
St/Ht Inlet
JHI"'.'
SUHt Outlet
Dt Inlet
Dt Bottom
Header an}
WW
f
S L�
Dist PI
Bot System
'p, 2,
'
Final Grade
OUIL 1. V VCK x Pressure Systems Only xx Mound Or At -Grade Svstems Only
Center
Bed/Trench Edges
COMMENTS: (Include code discrepancies. persons present. etc) Inspection #1
I Yes No I ( j Yes No
Inspection #2
Location: 718 MARTIN AVE �� <^x- n�
1 ) Alt BM Description - , U
2) Bldg sewer length = (rj
)- amount of cove
Plan revision Required? Yes No
Use other side for additional information
j,FIR% � � Date �Insepctor's,Si/gnat e
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J 1 1
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