HomeMy WebLinkAbout032-1064-30-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix
Safety and Building Division INSPECTION REPORT Sanitary Permit No. 633952
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No
Personal infornnation you provide may be used for secondary purposes [Privacy Law, a 15 04 (1 )(m)]
Permit Holders Name City Village Township Parcel Tax No
Jordan James I TOWN OF SOMERSET 032-1064-30-000
CST BM I linsip BM Elev. BM Description Sectionrrown/Range/Map No
I I I 24.31.19.320B
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
VenttoA,rintake
ROAD
Septic
Dosing
Aeration
Holding
PUMPISIPHON INFORMATION
Manufacturer
Dom no
GPM
Model Number
DH
Friction Loss
System Head
TDH Ft
Forc;ermam
Lou th
Dia.
Dist to Well
SOIL ABSORPTION SYSTEM
STATION
BS
HI
FS
ELEV
Benchmark
Alt. BM
Bldg, Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
HeaderlMan
Dist. Pipe
Bot. System
Final Grade
St Cover
ED/TRENCH
B DIMENSIONS
Width
Length
No. Of Trenches
-11
PIT DIMENSIONSINo
Of Pits
Inside Dia
I
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
I PIL
IBLDG
]WELL
LAKE/STREAJ
CLEACHING
HAMBER OR
UNI!
IManufacturer:
7W—, Of System
I Model Number
DISTRIBUTION SYSTEM
Header/Manifold
x Hole Size
Hole Spacing
11-ength
jDatnibution
Pipe(s)
Ix
D,,_
Length Dia_ Spacing
SOIL COVER x Pressure Systems Only xx Mound OrAt-Grade Systems Only
Depth Over
Depth Over
Depth of
Seecedl
xtr Mulch
Bed/Tranch Center
Bed/Trench Edges
I Topsoil
Ixx F] Yes E] No
I
COMMENTS: (include code discrepancies, persons present, etc )
Location: No Address Available
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover
Inspection #1.
Inspection #2:
Plan revision Requmed9 Yes L No
Use other side for additional information,
SBD-671 0 (R.3197) Date Insepolor's Signature
-- J
Cart No.