HomeMy WebLinkAbout020-1418-80-000Arisconsm Department of Commerce
Safety and Building Division
PRIVATE SEWAGE SYSTEM
County St. Croix
INSPECTION REPORT
Sanitary Permit No
GENERAL INFORMATION
(ATTACH T)
O PERMIT
633889
state Plan ID No
Personal Information you provide may be used for secondary
purposes [Privacy Law, s 15 04 (1)(m I]
Permit Holder's Name
Micheal & Kara Simkins
City Village Township
1
Parcel Tax No
TOWN OF HUDSON
020-1418-80-000
TANK INFORMATION
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Demi
GPM
umber
Forcemain ILength IDa (Dist to Well �I
Sf111 GRRf1RPTIr)IJ 13VQTrU
ELEVATION DATA
Bldg Sewer
St/Ht Inlet
Pipe
St Co,
BS
BED/TRENCH
DIMENSIONS
Width
Length
No Of Trenches
PIT DIMENSIONS
No Of Pits
Inside Dip
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
PL
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipes)
Length Dia Length Dia Spacing
x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
xx Depth of
xx Seeded: Sodded
Mulched
BedlTrench Center
BetllTrench Edges
Topsoil p
Yes NO
L Yee _ NO
COMMENTS: (Include code discrepencles, persons present, etc) Inspection #1 Inspection #2
Location: 852 DORWIN RD
1) Alt BM Description =
2) Bldg sewer length =
- amount of cover =
Plan revision Required? I Yes ❑ No
Use other side for additional information L
SBD-6710 (R 3/97) Date Insepctor's Signature
— Carl No
No