HomeMy WebLinkAbout040-1067-80-000 (2)Wisconsin 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 puwses [Pnvacy Law, s 15 04 (1)(m)]
permit Holder's Name City Village Township
Thoppas B. & Ardyce L. Oberg I TOWN OF TROY
CST BM Elev I lnsp BM Elev BM Description
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
PiL
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
I
:D;H
Lift —
E
Friction Loss
System Head
TDH Ft
F r dim ..
7L.n� th
Die
—
Dist to Well
SOIL ABSORPTION SYSTEM
Co—un'y St. Croix
Sanitary Permit No:
633911
State Plan ID No
Pa,col Tax No
040-1067-80-000
Sectionf-rown/Range/i No
17.28.19.257E
STATION
BS
HI
FS
ELEV.
Benchmark
Alt BM
Bldg Sewer
St/Ht Inlet
StlHt Outlet
Dt Inlet
Of Bottom
Header/Man
Dist. Pipe
Bot. System
Final Grade
St Cover
BEOFTRENCH
Width
Length
No OfTrenhes
PFTDIMENSIONS
No OfPits
Inside Dia
Liquid Depth
DIMENSIONS
I
I
SETBACK
SYSTEM TO
P/L
JBILDG
IWELL
LAKEISTREAM
LEACHING
M.n,facturer
INFORMATION
CHAMBER OR
UNIT
Type Of System
Model Number
DISTRIBUTION SYSTEM
Header/Mamfold
Hole Size
Hole Spacing
Vent to Air Intake
iLength_
ID,511bubon
Pli
ix
ix
I
Di _
Length Dia Spacmi
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
Depth of
SeededSodded
Mulched
Bedrrrench Center
Bedarench
Edges
Topsoil
Ixx [:] Yes
[:] No
1xx [:] Yes
COMMENTS: (Include code discrepencies, persons present, etc)
Location: 468 W OMAHA RD
1 ) Alt BM Description
2.) Bldg sewer length
- amount of cover
Plan revision Required9 [I Yes E] No
Use other side for additional information
Date
SBD-671 0 (R 3/97)
Inspection #1.
raccoons Signature
Inspection #2
Cart No