HomeMy WebLinkAbout026-1304-16-000 (2)Wisconsin Department of Commerce
PRIVATE SEWAGE SYSTEM
County St. Croix
Safety and Building Division
INSPECTION REPORT
Sanitary Permit No
GENERAL INFORMATION
(ATTACH TO PERMIT)
633940
State Plan 10 No
Personal information you provide may be used for secondary purposes [Pnvacy Law, a 15 04 (1)(m)]
Permit Holder's Name
Village Township
T—arrel Tax No
David & Pam Kieckhoefer
I TOWN OF =RIC=HMOND
026-1304-16-0
CST BM Elev Ilhap BM Elev
IBM Descnot,on
I
—'. -- --- , ---- i,-- — -:010
TANK INFORMATION
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPf,l
Model Number
D Lift Friction Loss System Head TDH Ft
F 0 ,e,,,, Lerl in Dia Dist to 'Nell
SOIL ABSORPTION SYSTEM
ELEVATION DATA
an
FS
BED'TRENC H
Width
Length
No Of T,e,che,,
PIT DIMENSIONS
No Of rib,
Insid Dia
Liquid Depth
DIM EN SION S
SETBACK
SYSTEM TO
I P/L
IBLDG
IWELL
LAKE/STREAM
LEACHING
Manufacturer
INFORMATION
CHAMBER OR
Type Of System
Model Number
UNIT
i I MIMIJ I IIJIN 0 T Z) I taf
Header/Manifold
Distribution
Hole Size
Hole Spacing
V
11-ength
Pipets)
iLength_
1x
Dla—
Dia_ Sharing_
OUIL �IJVICK X Prasugurs, Sv0arn. Emh, x� salinu.nd nr Af-int—A. Q—.— Airih,
Depth Cve�
Depth Over
SeededlSoddisid
Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
L
I
E] Yes �] No
Ll Y
COMMENTS: (include code discrepencies persons present etc Inspection #1
Location: 1611 92ND ST
1 Alt BM Description
2 Bldg sewer length
- amount of cover
Plan revision Required? F. Yes E] No
Use other side for additional information
SBD-6710 (R 3197) C ate ns.pi:or a 9,jnaturu
Inspection #2
Can No