HomeMy WebLinkAbout020-1307-10-000 (2)Wisconsin Department of Commerce
Safety and Building Division
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
MA Ion
H Ing
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
nd
GPM
MI el Number
TD
Lift
Friction Loss
System Head
TDH Ft
For main
Length
Dia.
Dis to Well
SOIL FISORPTION SYSTFM
ELEVATION DATA
County
St. CfOIX
Sanitary Permit No:
642297
State Plan ID No:
Parcel Tax No:
020-1307-10-000
ESectionrTown/Range/Map No.
27.29.19.1533
=won
:.
-MM
E• •
BED/TRENCH
DIMENSIONS
Width
✓TO
Length t
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside ia.
Liquid Depth
SETBACK
INFORMATION
SYSTEM
JPIL jF
LAKE/STREAM
LEACHING
CHAMBER OR
Ma c r
TOfSst
OI
5
J
Number
DISTRIBUTION SYSTEM - t
HeaderrMandold
x Hole Size
x Hole Spacing
Vent to Air Intake
/
IDistribution
Pipes)
Length Dia
Length Dia acing
SOIL COVER x Pressure Systems Only xx fdound Or At -Grade Svstems Only
Depth Over /�
Bed/Trench Center ` /�
Depth Over
Bed/Trench Edges � l�rt
xx th of
Tops
xx Seeded/Sa
u Ye No
xx e
es No
I_]
COMMENTS: (Include code discrepancies, persons present, etc.)
Location: 691 BLUE JAY LN
1.) Alt BM Description =
2.) Bldg sewer length =&k✓ f'� rAA
- amount of cover =lJ�
Plan revision Required? ❑Yes No l
Use other side for additional information.
SBD-6710 (R.3/97) Date
5�5 �io�rc Vll
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ors Signature Can. No.