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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR <br /> LABOR& HUMAN RELATIONS " SAFETY& BUIL, <br /> P.O.BOX 7969 PRIVATE SEWAGE SYSTEMS DIVIS, <br /> MADISON,WI 53707 BUREAU OF PLUMBIN. <br /> CONVENTIONAL ❑ALTERNATIVE ware Pla�I o.N�mbe,. <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound 111 aevlgoMl <br /> NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. <br /> INSPEC 10 DATE <br /> es ebs Y <br /> BENCH M.1 IPermanenr ...r cSTIar 1 GJL-S l�-��-pomrl DESCRIBE 8/IF DIFFERENT FROM PLAN <br /> REF.Pt/jE CST <br /> LREF.PTELEV <br /> /E/1V.. <br /> Name of Plumber V �/ ` _' ),-/)d L J <br /> MP/MPRSW N. co", SannarV Pe-11 Number'. <br /> Qc�r1U >� <br /> SEPTIC TANK/HOLDING TAN <br /> MANUF ACTUR EB <br /> LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV WARNING LABEL LOCKING COVER <br /> //�� cJ qO r� P O ICED. PROVIDED. <br /> C?( SLr D©lJ 73, S 1 / p / YES [:]NO OYES ONO <br /> BEDDINGE <br /> . VENT DIA. VNTMATL HIGH WgTER <br /> OYES ONO NUFEET FROM MBER OF ROAD'. PROPERTY WELL I BUILDING. VENT TO FRESH <br /> ALARM / LD E / p/o lYe AIR IrvLEr <br /> ❑YES ❑NO NEAREST too/00 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LIQUID CAPACI F PUMP MOCEL PUMP6IPHON MANUFACTURER <br /> WARNING LABEL LOCKING COVER <br /> ❑VES ONO PROVIDED. PROVIDED. <br /> GALLONS PER CYCLE: PUMP AND CONTROL.DPERATIONAL DYES ONO ❑VES ONO <br /> (DIFFERENCE BETWEEN NUMBER OF PROPERTY wELL BUILDING VENT TO FRESH <br /> FEET FROM LINE AIR INLET. <br /> PUMP ON AND OFF) ❑VES ❑NO NEAREST— <br /> SOI L ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> the soil is CITY enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> WICTH LENGTH NO.01 DISTH.PIPE SPACING COVER <br /> BED/TRENCH / INSIDE DIA -PITS uEINLET <br /> DIMEN$IOONS atL f TRENCHES MATE�••Rjjlq L' PIT D <br /> GRgVEL DEPTH FILL DEPTH DIST. Pill DISTR PIPE DI.TR.PIPE MATERIAL NO O <br /> BELOW PIPES 'Y gBpVE COVER ELEV INLET ELE V.END NUMBER OF PROPERTY WELL BUILDING V N <br /> G PES LINE <br /> FEET FROM <br /> jL <br /> {a_yJ,/ 4 ay $, yl^ .2702 NEAREST--. 710 0' DI <br /> '.�)r AIR <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. <br /> SOILCOVER ITESTURE PERMANENT MARKERS OBSERVA noN wEus <br /> DEPTH ovER rRENCFT BED DEPTH OVEH TRENCH.BEDDEPTH OF rOPsoIL soDOED ❑YES SEEC❑NO DYES NO <br /> cENTEv EDGES MULCHED <br /> ❑VES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESS UR IZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH No.OF LATERALSPACING. GRAVEL DEPTH BELDWPIPF FILL DEPTH ABOVE COVER <br /> DIMENSIONS <br /> RENCHES <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DIS TRI BUTION PIPE MATERIAL&MARKING <br /> . <br /> ELEVATION AND E LEV ELEV. DIA. ELEVPIPES CIA <br /> DISTRIBUTM <br /> INFORMATION HOLE SIZE HOLE SAC I NG DRILLEDCOHRECILV COVER MATERIAL VERTICAL LIFT CORRESPOND.TO APPROVED <br /> ., <br /> PLANS <br /> EYES ONO EYES ❑NO <br /> COMMENTS: PERMANENTMARKERS. OBSERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING. <br /> /� pp LINE. <br /> (jN•B S /, O� ❑YES Ll NO ❑VES ONO NEAR£ST� <br /> 7A>`k T <br /> 9, U 9,&'$Y 50u-t'iT•-e. l' to ha e 50, Owl ro )hay J+ NSI r T/ <br /> a q,1y q8,7 T°)q P')04?_" <br /> T.4 T 9, � q a,19 J <br /> 0 9, o <br /> N 19";l- S�S�er1 Ni I- S o•L,T, �SJ <br /> Sketch System on <br /> Reverse Side. Retain in county file for audit. <br /> SIGNAT E TITLE. <br /> DI LHR SBD 6710(R.01/82) /�/ <br />