HomeMy WebLinkAbout032-1090-40-000Aqsconsin 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 [Privacy Law s 15 D4 � 111 m I]
JPE�m t i s Name
I ruth crt, Allage To�,Ihio
I TOWN OF SOMERSET
CST 3M Bey I I n sp B M E e—v----FB M —D,,,,,pt ,
TANK INFORMATION ELEVATION DATA
Ing
TANK SETBACK INFORMATION
TANK TO
P�L
WELL
BLDG
/ant to Air intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
to
bUIL AbIbURIP I IUN SYSTEM
Dt Inlet
Pipe
Grade
BED'TREN CH
DIM ENSIONS
No Of Trenches
I
PIT DIMENSIONS
I
INC Of Pits
Inside D,a
I
Liquid Depth
I
79
SYSTEM TO
Fi
BLOG
JVVELL
I LAKEfSTREAM
I LEACHING
UbtK
NIT
IManufacturer
ype Of System
1
1
1 1
1
I Model Number
DISTRIBUTION SYS I
HeadeoMantold I 1P1!SP1,i,1ution Hole Size Hole Spacing Vernt to Air Intake
Leri Dia— lLength_ Cia_ Spacing_ ix 1"
x Pressure Systems Only xx Mound Or At�Grade Systems Only
Depth Over
Depth Over -----
T� Cepthof
Seeded/Sodded
Mulched
Bed/Trench Center
Bed,7rench Edga,,
Topsoil
lk�
I
[:] Yes No
L- Yes
COMMENTS: 01,11cle code discrepencies. persons present etc) Inspection #1 Inspection #2
Location: No Address Available
1 Alt EM Description
2 Bldg sevver length
- amount of cover
Plan revision Required? ::] Yes E] No
Use other side for additional information
S 8 D-671 0 (R 3/97) Date nsepctor�ignatur. Cart