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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 <br /> CONVENTIONAL ❑ALTERNATIVE $1.1.Plan l o.Numpe, <br /> ❑Holding Tank LlIn-GroundPressure E:1 Mound III—P-1 <br /> NA F PERMIT BOOLDEPo. C App p5/L�PET HOLDER (1 INSPECTION DATE <br /> 7 3 tl JLI N /(y\ I� 6 o s s q <br /> CH MARK IPerma ep CRI ERE R L <br /> REF.PL ELEV.'. CST REf.PT.ELEV <br /> /DD _7717' /,. J . %.� <br /> N- nl 14-1,11MP/ SW NP Sam+ary Permit Numbe <br /> y <br /> 7-717,�6? .35-0 <br /> E T K//r196B4Nri LANK: <br /> MANUFACTURER gCITV qN LET FLFV TANK PUT LET ELEV WARNING LABEL LOCKING COVER <br /> 1 �� PROVIDED PROVIDED <br /> 3 3 ]YES LINO INYEs ❑No <br /> BEDDING VENT DIA. VENT MALI HIGH " <br /> WATER NUMBER OF. ROAD PROPERTY WELL. BUILDING. VENINIRESH <br /> pf ALARM FEET FROM ( LINE/ A ) / qw INLET <br /> EI NO C�vS 12dVEs LINO NEAREST �bC� f S~ l ��3 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDUING 1-11111 'UM <br /> 111 I'APAI 11V {'UMP MI]ULI n P.SIII <br /> PUN MANl11 AI'.IIt11LH WARNING LABEL LOCKING COVER <br /> _ �QQ PROVIDED PROVIDED' <br /> DYES NO 5 � � - +'S t' VES ONO ❑YES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PRnCI TV wF1-1- BUILDING VENTTO FRESH <br /> (DIFFERENCE BETWEEN / FEET FROM LINE—/ A ��/ AIR INLET <br /> PUMP ON AND OFF) it OD YES ON <br /> NEAREST 3 e) <br /> SOIL ABSORPTION <br /> SYSTEM. <br /> Chesoil <br /> moisture <br /> PhofISIO nt9 O11rvIH / <br /> UTAAIF I/f/R LIATIHIAI ANDMARKN(, <br /> or excavation. rolled construction hatceaBe i ` RCE <br /> the soil is dry enough to continue) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH Nn nl DISIH P1PI SPACIN', COV"' 1NSnt Inn xvITS 1OUR' <br /> BED/TRiMRiI r / 7 IRI N)IUS �� MnTt H1 1'. DEPTH <br /> DIMENSIONS : p2 Q PIT <br /> GRAVEL H FILL DEPTN ...51R PIP. 15tH PtPC DISTR PIPE gTERIAL NO U[III NUM13JER OF PROPERTY WELL BUILDING VENTTOFREBH <br /> BE LUw P1P/5s geO..FIP�F C.v�R FIF/v 1rv1���LEV LVD, v1Pn FEET FROM uNE[, 1 /r -�J�9 AIR INLET <br /> (y J 7�_1 {y C_ :NEAREST—► ✓ /- 7 7 <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 ONO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TE.TUFF PI HMAN I N I VAHK11s OBSERVATION WE I IS <br /> _ [_]YES ❑NO —NO <br /> ONO <br /> DEPTH OVER THENCII BED DE P TII OVER THFNCII HE II III YI11111 IIII'yf tH ti111111fU❑ ]FFUI11 MULCHED <br /> CENTER EDGES <br /> VES. LINO OYES CNO ❑VES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENUTH NOOF LATERAL SPACING I:H4VLL UEPTII 01 UW PIPE FILL DEPTH ABOVE COVER <br /> BEDITRENCH. .. TRENCHES <br /> DIMENSIONS' <br /> MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATE141AL NO DISiH U15iH PIPE UISTHIBU I ION PRE MATERIAL&MAHKING <br /> =ELEV. ELEV DIA ELEV PIPE D1A <br /> ELEVATION AND <br /> DISTRIBVTION <br /> INFORMATION` HOLESIZE HOLE SPACING OHILL L D COTHFC I Ir COVER MATE IVAL VERT IC AL LJE T COHHESPONDS TO APPROVED <br /> PLANS <br /> OYES ❑NO ❑YES [:]NO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. NUMBERO.F. PROPERTY WELL BUI LOING. <br /> FEET FROM LINE <br /> 0 E 11 NO DYES ❑NO 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 />