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g a3 �o /a ' d-o <br /> DEPARTMEnAT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LA,9OR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 79s9 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 Slate Plan LD.Number: <br /> CONVENTIONAL ❑ ALTERATIVE (llassigned) <br /> ❑ Holdna Tank ❑ In-Ground Pressure ❑ Mound <br /> NAI PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA E: <br /> beo� s 8 . <br /> e tn1Z <br /> BENCH MARK( rmanent reteren a pointl DESCRIBE IF DIFFE ENT FROM PL N' REF.PT.E/L�J?.. CST REF.PT.ELEV.: <br /> Nameol (umber. MP/MPRSWNo.: Count : Sanitary Permit Number'. <br /> �S O l� <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY: TAN1 IfN ET ELEy.:/ TANK OUTLET ELEVr. WARNING LABEL LOCKING COVER <br /> / PRO (DED PROVIDED: <br /> U/ YES ❑NO [7YES MNO <br /> BEDDING: VENT DIA.: VENTMAT HIGHWATER NUMBER OF ROAD'. / PROPERTY' WELL: V BUILDINP'. VENT TO FRESH <br /> ( II ALARM: FEET FROM +� LINE C, / AIRINLET. <br /> E]YES NO "f CQ _ ❑YES O NEAREST-1111' / 7� �/ .5 �° 6 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIOU ID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER: WARNING LABELLOCKING QOVER <br /> PROVIDED: PROVIDED'. <br /> ❑YES ED NO LJ YES ED No <br /> ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINEAIR INLET. <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST---lllll� r <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING'. <br /> or excavation. (It soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH NOOF DISTR.PIPE SPACING: COVER INSIDE DIAr. #PITS: LIQUID <br /> BED/TflENCH / � TRENCHES'. // / MAS5ERIAL' PIT DEPTH: <br /> DIMENSIONS 53 b ST L,) <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE I DISTR.PIPE MATERIAL NO DISTR. NUMBER OF PROPERTY / WELL: BUILDING VENT TO FRESIj <br /> BELOWPIPES' ABOVECQVER� ELEV INLI� ELEVE ��� PIPES: FEET FROM LINE ,� �/ AIR INLET <br /> A/ <br /> e( ( `( _J7 NEAREST� / 7 b EX/ <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVER I TEXTURE'. PERMANENT MARKERS-. OBSERVATION WELLS', <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED'. SEEDED'. MULCHED. <br /> CENTER: EDGES: <br /> ❑YES ❑NO ❑YES ❑NO [--I YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH'. LENGTH: NOOF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> DIMENSIONS TRENCHES' <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: <br /> ELEV(. ELEVr. DIA.'. ELEV.'. PIPES: DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES [_1 NO ❑YES El NO <br /> PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL'. BUILDING: <br /> COMMENTS: FEET FROM LINE'. <br /> I ❑YES ❑NO ❑YES ❑NO NEAREST----► <br /> �S <br /> 1�•lc3�v <br /> S(J�h )(R8) <br /> Retain in county file for audit. <br /> R SIGNATURES <br />