HomeMy WebLinkAbout042-1033-10-020 (2)VVisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Per;onaj information you provide may be used for secondary purposes [Privacy La� s 15 04 (1 )1 n-)]
1per,rit Holder's Name Cit� village Town hip
LRelecca & Bruce Mann T05WN OF WARREN
TANK INFORMATION
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
vent to Air intake
ROAD
Septic
Dosing
Aeration
Holding
PUMPISIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift tem Head TDH- Ft
Forcernam Length Dia r to vVell
SOIL ABSORPTION SYSTEM
ELEVATION DATA
STATION
BS
HI
FS
ELEV
Benchmark
Alt BM
Bldg Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header'Man
Dist Pipe
Bot System
Final Grade
St Cover
BEOfTRENCH
DIMENSIONS
Width
Length
I
No Of Treh.hes
I
I
PITEAMENSIONS
I
NO QfPlts
I
Inside Do
I
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
—
IP/L
JBLDG
IWELL �E/S�TREAM
� CLEACHING
HAMBER OR
UNIT
INIanufact.rei-
Type Of S� ft em
Model Number
W10 I MIDUHUPI OT a! rnfl
Header�Manifold
D,shbution
Hde Size
Hole Spacing
Vent to A,r Intake
Pipeis)
I
Length_ Da—
Length_ Dia_ Spacing
ZiUll- �;UIVI-ht x Pressure Svqtpm-q 0nIv �. Mound nur At.r.r.dei n.h,
D epth 0...
Depth Over
—7—seedediSodded
Depth of
Mulch
Bed/Trench Center
I
BedfTrench Edges
1
Topsoil
1"
1 [:] Yes [:] No
COMMENTS: (Ind,cle code discrepencies, persons present etc I Inspection #1 Inspection #2
Location: 994 150TH ST
1 ) Alt BM Description
2.) Bldg sewer length
- amount of cover
Plan revision Required? [ 1 Yes ' ] No I
Use other side for additional information
SBD-6710 (R 197) Date Insepctors Signature Cert No