HomeMy WebLinkAbout040-1061-20-000 (2)'Arsconsin Depanninent 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 [Pnvacy Law s 15 04 (1)(m)]
Permit Holder's Name I r.", Vill�nP Tn ... —h-
nsp
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
Pil-
WELL
BLDG
ent to 4ir Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMPISIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
DH Friction Loss System Head TDH Ft
F re,,,n L,, th Dia Cict to Well
61JIL A135ORPTION SYSTEM
TOWN OF TROY
ELEVATION DATA
S"I Intel
.5111-1 t Outlet
D t �
I let
Dist Pipe
'Fot System
I
BEDITRENCH
DIMENSIONS
Width
Length
I
No C Trenches
PITDIMENSIONS
No OfPpis
Insid Dia
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
P/L
JBLDG
JVVELL
LAKE/STREAM
LEACHING
CHAMBEROR
UNIT
Man,facturer
Type Of System
Model Number
L)[,)IKlt$UIIVN ZTZ)It:M
Header/Manffold
Distribudon
Hole Size
Hole Spacing
ii-ength—
ix
Dia
JP,pe(s)
Length_ Dia_ Spacing_
bIJIL. UUVLK at Pressure Svslarns Oniv ry Mniind Or At-11,nd[o tttvcf�m� nrdu
Depth Over
Depth Over --711
Depth of
Seed.d/S.dd.d
Mulched
Bed/Trench Center
Becl Edges
Topsoil
1. —1
I
Yes E] No
1:1 Y
COMMENTS: (Include code discrepancies, persons present, etc) Inspection #1
Location: No Address Available
I ) Alt BM Description
2 ) Bldg sewer length
- amount of cover
Plan revision Required? El Yes E] No
Use other side for additional information
SBD-6710 iR 3197) Dale Insepctor's Signature
Inspection #2
Cent No