HomeMy WebLinkAbout020-1495-29-000Wisconsin 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 secondary purposes (Privacy Law, s 15 04 (1)(mll
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
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
71P
Friction Loss
System Head
TDH Ft
th
Dia.
Dist to Well
SOIL ABSORPTION SYSTEM
County St. Croix
Sanitary Permit No:
642235
State Plan ID No:
Parcel Tax No
020-1495-19-000
Sechon/Town/Rair lMap No
35.29.19.3206
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
BED/TRENCH
Width
Length
No Of Trenches
Prr DIMENSIONS
No Of Pits
Inside Dia.
Liquid Depth
DIMENSIONS
SETBACK
SYSTEM TO
P/L
BLDG
WELL
LAKE/STREAM
LEACHING
Manufacturer
INFORMATION
CHAMBER OR
UNIT
Type Of System
Model Number
DISTRIBUTION SYSTEM
Header/Manifold
iDistnbution
x Hole Size
x Hole Spacrng
Vent to Air Intake
Pipe(s)
Length Dia
Length Dia Spacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
xz Mulched
Bed/Trench Center
Bedr-rench Edges
Topsoil
❑ yes ❑ No
El yes No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:
Location: No Address Available
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover -
Plan revision Required? _ Yes _ No
Use other side for additional information.
Dale
SBD-6710(R 3197)
Insepctors Signature
Inspection #2.
Cart No