HomeMy WebLinkAbout648495 042-1085-60-610
County:
Wisconsin Department of Commerce
Tu/!Dspjy
PRIVATE SEWAGE SYSTEM
SAN-2023-107
Safety and Building Division
Sanitary Permit No:
INSPECTION REPORT
7595:6
(ATTACH TO PERMIT)
State Plan ID No:
GENERAL INFORMATION
Personal information you provide may be used for secondary purposes \[Privacy Law, s.15.04 (1)(m)\].
Parcel Tax No:
VillageTownship
Permit Holder's Name:
City
!!HMFOSJEHF!QSPQFSUJFT!MMD
153.2196.71.721
UPXO!PG!XBSSFO
CST BM Elev:Insp. BM Elev:BM Description:
Section/Town/Range/Map No:
42/3:/29/58:B.721
TANK INFORMATIONELEVATION DATA
TYPEMANUFACTURERCAPACITYSTATIONBSHIFSELEV.
SepticBenchmark
DosingAlt. BM
AerationBldg. Sewer
HoldingSt/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
Vent to Air Intake
TANK TOP/LWELLBLDG.ROADDt Inlet
SepticDt Bottom
DosingHeader/Man.
AerationDist. Pipe
HoldingBot. System
Final Grade
PUMP/SIPHON INFORMATION
ManufacturerDemand
St Cover
GPM
Model Number
TDHLiftFriction LossSystem HeadTDH Ft
Dist. to Well
ForcemainLengthDia.
SOIL ABSORPTION SYSTEM
WidthLengthNo. Of TrenchesNo. Of PitsInside Dia.Liquid Depth
BED/TRENCH PIT DIMENSIONS
DIMENSIONS
Manufacturer:
SETBACK LEACHING
SYSTEM TOP/LBLDGWELLLAKE/STREAM
INFORMATIONCHAMBER OR
Type Of System:
UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/ManifoldDistribution x Hole Sizex Hole SpacingVent to Air Intake
Pipe(s)
Length________ Dia________Length_________ Dia_________ Spacing_________
SOIL COVER
x Pressure Systems Onlyxx Mound Or At-Grade Systems Only
Depth OverDepth Overxx Depth ofxx Seeded/Soddedxx Mulched
Bed/Trench CenterBed/Trench EdgesTopsoil
YesNoYesNo
COMMENTS:
(Include code discrepencies, persons present, etc.)Inspection#1:Inspection #2:
Location:
Op!Beesftt!Bwbjmbcmf
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required?YesNo
Use other side for additional information.
DateInsepctor's SignatureCert. No.
SBD-6710 (R.3/97)
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