HomeMy WebLinkAbout020-1495-33-000Wisconsin 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 seccndar; purposes IPnvay Lam s 15 iY I1:(mQ
Permit Holder's Name qlf Village To,vnship
Urchins LLC TOWN OF HUDSON
CST BM Elev Insp 6M Elev IBM Descnohon
TANK INFORMATION
TANK SETBACK INFORMATION
TANK TO
PIT
WELL
BLDG
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
Friction Loss
System Head
TDH Ft
Forcemain
Length
Dia
Dist to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
Sewer
Dt Inlet
Dt Bottom
St Cover
BE
BEDITRENCH
DIMENSIONS
Witlih
Length
No Of Trenches
PIT DIMENSIONS
No Of Pits
Inside Die
Liquid Depth
SE78ACK
INFORMATION
SYSTEM TO
I P/L
JBLDG
JVVELL
ILAKEISTREAM
I LEACHING
CHAMBER OR
UNIT
IManufacturer
Type Of System
Model Number
UIS I KIOU I IVIN DTJ I tM
Header;Man:fold
Datnbut:on
z Hale Size
x Hole Spacing
'✓ent to A:r Intake
pipe: s)
Length Dia
Length Dia Spacing
JVIL GUvtK X Pressure Svstems Only xx Mound Or A6gradn Rvcfeme rinty
Depth Over
Depth Over
xz Depth of
xx Seeded/Sodded
xz Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
❑ yes No
IJ Ves No
COMMENTS: (Include code discrepencies, persons present. etc) Inspection #1 Inspection #2
Location: No Address Available
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? I Yes _ No
Use other side for additional information
SBD-6710 (R 397) Date Insepctor's Signature
t
Cat No