HomeMy WebLinkAbout016-1051-95-025 (3)Wisconsin 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)(m)].
Permit Holder's Name: City Village X Township
j Laberee Lavern A. & Jolene I Glenwood, Town of
CST BM Elev: Insp. BM Elev: BM Description:
o6,*
/o 6 --b I C
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
f1
M
MPI HON INFORMATION
urer
Demand
GPM
Model Number
TDH
Lift
Friction Loss
System Head
TDH Ft
Forcemain
Length
Dia.
Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches
DIMENSIONS��-
SETBACK SYSTEM TO // PIL BLDG
INFORMATIONITYPystem: :�
DISTRIBU.TION SYSTEM IIWA,
County: St. Croix
Sanitary Permit No:
572816 0
State Plan ID No:
Parcel Tax No:
016-1051-95-025
Section/Town/Range/Map No:
23.30.15.367A
STATION
BS
HI
FS
ELEV.
Benchmark
oe83
Alt. BM
Bldg. Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Head "/Man.,
A)
Di s '
ot
Bot. System ,
�
Z
161
Final Grade
St Cover
3.
/a C)
PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
WELL LAKE/STREAM CHING Manufacturer.
dc CHA ER OR
Model Number:
I
I'
rHed anifold
Distribution , ,
'
� .l �:3
x Hole Size
� . � �I
x Hole pacing
d
�. 0dgth
Vent,to Air Int e//•Pipe(s)
� I �r
Dia
Length Dia Spacing__41
a -Aa.
SOIL COVER x Pressure Svstems On[v "ouAd'9r At -Grade Svstems Only _A•t.J, 2
Depth Over
Depth Over Depth
roc CLeede Sod
xx Mulched
Bed/Trench Center
Bed/Trench Edges
~�7
.>- es <0 No
0 Yes No
b
COMMENTS: (Include code discrepencies, persons present, etc.) lUgection, #1: �� / 1� Inspection #2: / /Alf U'r �
, P
Location: 1455 310th Street Glenwood City, Wl 54013 (SW 1 /4 NW 1 /4 23 T30N R15W) >35 ac Lot Parcel No: 23.30.15.367A
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1.) Alt BM Description
r
2. Bldg sewer length = �A_
) 9 9 �c�
amount of cover
Plan revision Required? ] Yes No
Use other side for additional information. _
SBD-8710 (R.3l97) Date lnsepctors Signature
Cert. No
c71-
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