HomeMy WebLinkAbout040-1328-22-000VVisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you pro,dis may be used for secondary purposes [Pn vac� La� s 15 C4 11 mri �]
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
vent to Air intake
ROAD
Septic
Dosing
Aeration
Holding
PUMPISIPHON INFORMATION
A a
Number
:JUIL At$Z5UKF I IUN 5Y5TI=M
STATION
BS
HI
FS
ELEV
Benchmark
Alt BM
Bldg Sewer
St'Ht Inlet
St,Ht Outlet
Dt Inlet
Dt Bottom
Header/Man
Dist. Pipe
Bet System
Final Grade
ST Cover
BEDITRIENCH
DIMENSIONS
Width
Length
I
No Of Trnnch.�
I
PIT DIMENSIONS
I
IN. Of Pits
Inside Dra
I
Liquid Depth
I
SETBACK
INFORMATION
SYSTEM TO
PIL
BLDG
WELL
�KFJ�STREAM
� CLEACHING
HAMBER OR
UNIT
]Manufacturer
I
Type Z�f System
i Model Number
I." I Kibsu I IUIN b yZ5 I LM
Header Manifold
Distribution
Hole Size
Hole Spacing
Vent to 4ir Intake ---
iluerl
J,r
jPipe(s�
D,a_
I-ength Die Spacing_
')UIL LUVLK
x Pressure Systems OnIv xx Mound Or Atr�Grada Sv%tam-q Onto
Depth Over
Depth Over
Depth of
Sedded/Sodded
M
Bed/Trench Zents,
Bedi-prench Edges
To
1� psod
L] yes ::] No
COMMENTS: (Include code discrepancies, persons present. etc )
Location: No Address Available
1 ) Alt LIM Description
2 ) Bldg sewer length
- amount of cover
Plan revision Requiredo F- Yes — No
Use other side for additional information I
Date
SBD-6710 iP 3 97�
Inspection #1
Insepotors Signature
Inspection #2
_J
Cert No