HomeMy WebLinkAbout040-1329-52-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 648410
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village Township Parcel Tax No:
TOWN OF TROY 040-1329-52-000
CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown/Range/Map No:
17.28.19.2352
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
TDH
Lift
Friction Loss
System Head
TDH Ft
Forcemain
Length
Dia.
Dist. to Well
SOIL ABSORPTION SYSTEM
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg. Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BEDITRENCH
Width
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
DIMENSIONS
SETBACK
SYSTEM TO
I P/L
JBLDG
1WELL
LAKE/STREAM
LEACHING
Manufacturer:
INFORMATION
CHAMBER OR
UNIT
Type Of System:
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold
I Distribution
x Hole Size
x Hole Spacing
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
xx Mulched
Bed/Trench Center
Bedfrrench Edges
Topsoil
0 Yes 0 No
0 Yes � No
COMMENTS: (Include code discrepencies, persons present, etc.)
Location: 479 MICHAEL CT
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? [* Yes [* No
Use other side for additional information. I� JI�I JI
Date
SBD-6710 (R.3/97)
Inspection #1:
Insepctor's Signature
Inspection #2:
Cert. No.