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DEPARTMENT OF INDUSTRY, 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 )i <br /> CONVENTIONAL ❑ALTERNATIVE Slate Plan l o.Number. <br /> ❑Holding Tank E:1 In-Ground Pressure El Mound o f.Gen.l <br /> NAM OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE <br /> e/v+�5 m• imo.s � (i� I Srren l �Gl& �a <br /> BENCH MARK(Permanneennt"'a—G,Ann,;DESCRIBEIF DIFFERENT FROM PLAN. REE PT.ELEV.'. CST RAF PLELEV. <br /> • t /.NM✓f/1 / �A� <br /> v <br /> Name of Plumper ✓ MP/MPgSW No County SannarV Permu Numher. <br /> N Oar I 3 3 13c��,t �.z�`_ S a �3� <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFgCTURER. LIDVID CAPACITY. TAN INLET ELE V. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER <br /> P OVIDED. PROVIDED <br /> '�� lJL x YES ONO OYES <br /> ONO <br /> BEDDING. VENTDIA. VENT MAIL. HIGH WqT R NUMBER OF ROAD. PROPERTY WELL BUILDING. VENT TO FRESH <br /> ALARM LINE. _ AIR INLET. <br /> vY FEET FROM ( �' / <br /> OYES NO ❑VES ONO NEAREST / �u <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDEDPROVIDED. <br /> ❑YES ONO OYES [_1 NO ❑VES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS oPERAnorvgL. NUMBER OF PROP,HTv WELL Bu1LDINr, VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LIN <br /> AIR INLET <br /> PUMP ON AND OFF) OYES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAME T,N MArERwL ANN MARKINrf <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 /> WIDTH LENGTH NO OF DISTR PIPE SPACING COVER INSIDE OF, .PITS LIQUID <br /> BED/TRENCH t THE NCH Es ` MATERIAL. PIT DEPTH. <br /> DIMENSIONS j `3 S-t <br /> GRAVEL DEPTH FILL DEPTH UISTH PIPF pISTq PIPE DISTR,PIPE MATERIAL NO DISTR NUMBER OF PROPERTY Bm LpING VENT TO FRESH <br /> BE LOW PIPES gBOVE COVER EIEV.WLET ELEV.END PIPES LINE gIRINLE.. <br /> S i /f _ L y-�L,. 'S FEET FROM <br /> 4 / _J NEAREST I t G '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 /> ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TEXTURE PERMANENT MARKERS OBnERVATION WELLS <br /> ---------------------- <br /> ❑YES ❑NO OYES ❑NO <br /> DEPTH OVERTHENUH:BED UEPTf10VER TRENCH;BEU DEPTH UFTOPSOIL SODDED SEEDED MULCHED <br /> CENT," EDGES <br /> DYES ENO DYES IJ NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH TR0 OF ENCHES LATERAL SPACIN G. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVE" <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL Is MARKING <br /> ELEV. ELEV. CIA ELEV. PIPES DIA.' <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> vLgms <br /> 11 YES ❑NO 1:1 YES LINO <br /> f.`OMMENT.S`] PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING <br /> FEET FROM LINE. <br /> ❑VES I]NO ❑VES LINO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE. TITLE. <br /> DILHR SBD 6710 (R.01/82) <br />