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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.,BOX P9¢9 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> CONVENTIONAL 1-1 ALTERNATIVE sLre Plzo LD NumBer. <br /> H easrgnerl l <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME PERMIT HOLDER.^ ADDRESS OF PERMIT/H\OLDEPP� �DI INSPECTI NDq T6) <br /> t <br /> BENCH MARK IPe•ma—trefereneepp—O DESCRIBE IF DIFFERENT FROM PLAN CY 'LT'INEI REF,PT,I LEV.. CSTR F PT ELEV <br /> Narne o Plum MPIMPq SW Nn Cnu•�t Sanrtar P rmn Numtrcr. <br /> bd I JS x,51 <br /> SEPTIC TANK/H6tDH46 FAA/K: _ <br /> MANUFACTURER LIQUID CAPACITY TANK INLET ELFV TANK OUTLET ELFV Wq RAIN G LABEL LOCKING COVER <br /> / / �/ y �/ PROVIDE PROVIDED <br /> /� (,. / 5 0 /� J (7 � �'E L1�,❑NO DYES LINO <br /> BEDDING. VENTDIA VENTMAT 1111 HWq TIED NI/MBER OF. R040. PROPERTY W +U BV ILOING VENT TO FRESH <br /> 1• nLnHM FEET FROM .1 LINyE U 7J(.�/ AIR INLET <br /> ❑VES NO YES LIN NEAREST / � " J a^' <br /> DOSING C AMBER: <br /> MANUFACTURER BEDDING LIDUIn I APAt_I IY 'I'M"M[IUFI 'UMP.EIPIIIIN MANUI AI.I IIHE 11WARNIN LABEL LOCKING COVER <br /> PROVID D. PROVIDED <br /> ❑VES ❑NO ❑V S ONO OYES ONO <br /> GALLONS PER CYCLE: PUM P AND CONTROLS OPERATIONAL NUMBER OF III1PFHTY WELL BICILDINI. VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROMLINE AIR INLET <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoll molstureat thedepth of plowing '. nNonl u1nMFTfH Mgrt HIAI AND MAHKINII <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> the soil is dry enough to continue.) <br /> MAIN <br /> CONVENTIONAL SYSTEM: <br /> BED/FRNwmTH LENGTH No F PPyIA:N vEPIT I'll vn5 <br /> ILIOLID <br /> TOD <br /> nTwDEFT" <br /> DIMENONS /Y Zc <br /> CHAVrL DEPTH FILL DEPTH UlSlll PIPE UISTH PIPf DISTR PIPE MATERIAL NO UISIN DUMBER Qr. PH OPERTv WELL 9LIILDING VENT TO FRESH <br /> BE LOW PIPET ABOVE covEfy tlEv INu} ELEv wD PrvLs FEET FROM uNE yD r _ AIRINLETI, <br /> T <br /> l� .(. � ' /Or f J�t I � �� � NEAREST---�► // LU ' .Z-� /{ <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> El YES NO <br /> SOIL COVER TEXTURE numinNl N I n1AIIK1 ns 11 1111111 1110 wF us <br /> ❑YES ONO ED YES LINO <br /> uEP1111VfH THENt:II BEu DEPi11 DVFH IHENCIl of 11 11 PIH 1I TIIPSIIIL \IlllllF 11 SfLUrll MULCHED <br /> cENTEq EDGES <br /> ❑YES. ❑NO ❑VES _ NO [-]YES L]NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WICTH LENGTH NO OF LATERAL SPACINI, 1HAVEL UFPT.N f L UW PIPI FILL D PTH ABOVE COVFR <br /> BED/TRENCH. TRENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFDID DISTR PIPE MANIFOLD MAiEHIgL NQ UISTH DISTR PIPE DISTHI U110N PIPE MATERIAL&MARKING <br /> ELEV ELEV CIA ELEV. PIPES DIA. <br /> ELEVATION:AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPAOINo DIau L D COHIU CI I v COVIR MATEHIAL VEAH1s AL OF T CORRESPONDS TO APPROVED <br /> EYES ❑NO ❑VES ONO <br /> COMMENTS: PERMANENT MARKETS _.i ERVATIONWELLS NUMBEROF ROPERTV WELL RUILCING <br /> FEET FROM.. InE <br /> ❑YES <br /> ANO DYES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. " <br /> Reverse Side, <br /> SFAANRE TITLE <br /> DI LHR SBD 6710 (R.01/82) 4 -Gz 1, <br />