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DEPARTMENT OF 1NDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR'& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O. BOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> ❑CONVENTIONAL LJ ALTERNATIVE Slate Plan I.D.Number. <br /> ❑Holding Tank ❑ In-Ground Pressure ❑ Mound (11 assigned) <br /> NAME OF PERMIT HOLD ADDRESS OF PERMIT HOLDER: INSPECTION DATE. <br /> BENCH MARK(Permanem refe..ri eo nrnj DESCRIBE IF DIFFERENT FROM PLAN: REE_PT.ELEV.: CST HEF.PT.ELEV.. <br /> Name of Plumber MP!MPRSW No.: Coumy San,",,Permit Number. <br /> /7 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLETELEV. WARNING LABEL LOCKING COVER <br /> ®YK <br /> PROVIDED. PROVIDED <br /> C) ' <br /> �v <br /> ES ENO YES ENO <br /> BEDDING: VENT DIA.: VENT MATL / HIGH WA FR NUMBER OF, ROAD: PROPERTY WELL BUILDING. VENTTOFRESH <br /> ( YS "� ALARM. FEET FROM 1 /''/`/ / LINE: / /'� f r AI INLET <br /> EYES ENO (�I/ 1 YES ❑NO NEARErST' C/iA / _CI✓{l(.J 1 JC C/19 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING: LIOUIDCAPACITY PUMP MODEL. PUMPi SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED: <br /> EYES LINO I I DYES ❑NO ❑YES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBEROF ]..,:..PROPERTY WELL. BUILDING I VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: <br /> PUMP ON AND OFF) I DYES ONO NEAREST30 <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE "LENGTH DIAMETER MATERIAL AND MARKING <br /> or excavation, (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> n S WIDTH. LENGTH NO.OF nISTR PIPE SPACING. COVER INSIDE DIA. #PITS LIQUID <br /> IRE}/TRENCH TRENCHES. MATERIAL PIT DEPTH. <br /> DIMENSIONS <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIFF UISTH.PIPE 10151R.PIPE MATERIAL NU.UISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> BELOW PIPES ABOVECOVER EI FV.I VI FT ELEV END PIPES: FEET FROM ',LINE. AIRINLET. <br /> NEAREST---i <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <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 ENO <br /> SOIL COVER TFKTHHP PERMANFNT MARKERS. ORSFRVATION WELLS. <br /> EYES ❑NO ❑YES ❑NO <br /> DEPTH OVER THENCHBEU DEPTH OVER TRENCH' DEPTH OF TOPSOIL SODDED. SEEDED MULCHED <br /> CENTER EDGES. <br /> [—]YES ❑NO DYES ONO ❑YES 1:1 NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> :..'WIDTH LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: INC).UISTH DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.: ELEV DIA, ELEV.: PIPES DIA: <br /> ELEVATION AND <br /> DISTRIBUTION 'HOLE S17F HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT UGHHESPONDS TO APPROVED <br /> INFORhAATION PLANS. <br /> ❑YES ENO I DYES ENO <br /> COMMENTS: PERMANENT MARKERS OBSERVATION WELLS: NUMBER,OF, PROPERTY WELL: BUILDINGr <br /> FEET FROM LINE <br /> DYES Ll NO DYES 1:1 NO NEAREST 01 <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATy!/�E���� D TITLE <br /> .J <br /> DILHR SBD 6710(R.01/82) <br />