HomeMy WebLinkAbout042-1057-40-100PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
Wisconsin Department of Commerce
Safety and Building Division
GENERAL INFORMATION
TANK INFORMATION
TANK SETBACK INFORMATION
PUMP/SIPHON INFORMATION
SOIL ABSORPTION SYSTEM
DISTRIBUTION SYSTEM
SOIL COVER
COMMENTS:
ELEVATION DATA
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name:
CST BM Elev:Insp. BM Elev:BM Description:
County:
Sanitary Permit No:
State Plan ID No:
Parcel Tax No:
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
TANK TO P/L WELL BLDG.Vent to Air Intake ROAD
Septic
Dosing
Aeration
Holding
Manufacturer
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia.Dist. to Well
Demand
GPM
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
BED/TRENCH
DIMENSIONS
Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia.Liquid Depth
SETBACK
INFORMATION
SYSTEM TO P/L BLDG WELL
Type Of System:
LAKE/STREAM LEACHING
CHAMBER OR
UNIT
Manufacturer:
Model Number:
Header/Manifold
Length________ Dia________
Distribution
Pipe(s)
Length_________ Dia_________ Spacing_________
x Hole Size x Hole Spacing Vent to Air Intake
x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed/Trench Center
Depth Over
Bed/Trench Edges
xx Depth of
Topsoil
xx Seeded/Sodded xx Mulched
Yes No NoYes
(Include code discrepencies, persons present, etc.)
Location:
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Inspection #1: Inspection #2:
City Village Township
Section/Town/Range/Map No:
Plan revision Required?Yes No
Use other side for additional information.
Date Insepctor's Signature Cert. No.SBD-6710 (R.3/97)