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ILJ-9_ 1 Itl0D <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> BUREAU OF PLUMBING <br /> P.O.BOX 7969 <br /> MADISON,W 153707 <br /> CONVENTIONAL ❑ALTERNATIVE stale Planent D.Nnmea. <br /> Ill asal9 <br /> ❑Holding Tank ❑ In-Ground Pressure E-1El <br /> Mound - <br /> TE <br /> NAM F,PERMITH LDE W. q ESSRMIT HOLDEj/g ��� INSPECT?—A1 <br /> .41 Tj <br /> BENCH MARK IPermanem rele.ence pomn`DE�SCRI6E IF DIFFERENT FROM PLAN REF.PT.ELEV.: Cyt REF.PT.ELEV <br /> Name ,o Ober / MP/MPRSW No.. C. S+nlurY Permit NumGer ' <br /> ��� S J [�r>P Ido ISO <br /> SEPTIC TANKpIgC13110IYtNK: <br /> MANUFACTURER LIpUID CAPACITY. TANK INLET ELEV TANK OUTLET ELEV. WARNING LAB L LOCKING COVER <br /> OD PgOV YES PflOVIDEP. <br /> VES ❑NO El ONO <br /> BEDDING VENT DIq. VENT MgTL. HIGH WATE NUMBER OF ROAD'. PROPERTY WELL 9UILOING. VENT TO FRESH <br /> ALARM ���� LJNE.� l y AIfl INLET <br /> FEET FROM 33 a 7 <br /> ❑VES �NO 1:1 YES 1:1 NO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMPISIPHON MANUFACTURE WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED. <br /> ❑VES ❑NO ❑YES ❑NO DYES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHnPEgTv WELL BUILmNr. vENTro FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) ❑VES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moisture at the depth of plowing LENGTH DIAME TEH MATERIAL AND MARKING <br /> or excavation. (If soil can be rolled into a Wire,construction shall cease until FORCE <br /> the soil is dry enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: - <br /> WIDTH LENGTH No.of DISTR PIPE SPAcmc COV <br /> INSIDE DIA atPlrs LIQUID <br /> BEDENSIONS /_ TRE�CHFS M RIAL' PIT DEPTH <br /> DIMENSIONS I� <br /> GRAVEL DEPT FILL DEPTH UISTn PIP_ DISTR PIPE DISTR PIPE MATERIAL NO.DIST NUMBER OF PROPERT WELL BUILD' VENT TO FRESH <br /> BELOW PIPys J7 AeoyvE cgvµ EIErv�NLFI EL��N� I /,J I/'C PIPEs FEETFROM _ LINE "� 10 � AIH IyL T <br /> CJ// aL�/7L NEAREST [/7 <br /> MOUNDSYSTEM: <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 /> ❑YES ❑NO <br /> SOIL COVER TExTUNI, vEHMANENI MAHKFHs OHOIIIgT1oNWl us <br /> _ <br /> ]YES ❑NO EYES ONO <br /> DEPTH OVER TRENnCeED DEPn1oVER TRENCH:BED DEPTH DF TOPSDIL SOIDEI, SELL"' <br /> MVLC'ED <br /> CENTER EDGES <br /> ❑VES ❑NO ❑YES ❑NO ❑VES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> P <br /> WIDTH LENGTH NO.OF LATERAL SPACIN(: (:RAVEL nETH BELOW PIPE FILL DEPTH ABOVE COVER <br /> BED/TRENCH TRENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLDMATEHIAL INTO 015TH UISiR.PIPE UISTHIBVIIONPIPEMATFHIAI&MAHKINti <br /> ELEV. ELEV DIA ELEV. PIPES DIA <br /> ELEVATION AND <br /> DISTRIBUTION TOLESIIE HOLE SPACING DRILLED COHHECTLV CQVER MAT ERIAL VEHTIC.AL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> DYES ❑NO ❑VES ❑NO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF LIRNEERTY WELL. BUILDING <br /> I FEET FR <br /> 0E ❑NO El YES 1:1 NO NEARESTOM <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNAT E TITLE <br /> DILHR SBD 6710(R.01/82) <br />