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REPORT ON INSPECTION OF SANITARY PERMIT # /13Y6 <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection <br /> /r d �, �- l'2 -�1 <br /> Name, Addressr LIcense NO. OT Installing PT umber Time of Inspection <br /> 3 INSTALLATI CONSISTS 0 Z:¢eptic Tank D Seepage Trench D Dosing Chamber <br /> ❑Seepage Pit ® Seepage Bed ❑ Holding Tank ❑ Fill System <br /> )BENC......RK: (. ermanen reference in escri e: <br /> '5 �J_'6-t- <br /> Elevation of vertical reference point: 1 O U Slope at site: 61 <br /> (5)MATERIAL AND DEPTH OF SEWER: e14 C �A, ?�6 <br /> W SEPTIC TANK: Manufacturer: 7-At G Liquid Capacity: <br /> Tank Inlet Elevation : Tank Outlet Elev: <br /> # ft to lot or property line D' # ft to well : -3 ,$_ <br /> (7)DOSING TANK: Manufactur i of gallons : <br /> # of gallon pump set for a cycle gallons ; total capactiy of distribution <br /> lines gallon; si pump head; gallon per minute <br /> horsepower Li rand name of pump and mo a mber <br /> Is the warning device installed? ❑YES ❑NO Wired? DYES ❑NO <br /> 8 HOLDING TANK: Manufacturer o ga ons ; <br /> construction ; depth to cover ft; If septic tank is <br /> being used are baffles removed? YES N0; ft from residence; <br /> am <br /> ft from well ; ft fro t line. Type of warning device <br /> Is the warning device installed? ❑ YESN9; Wired? []YES ❑ N0; <br /> Locking device on cover? YES ❑ NO; Dieter of vent and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: its; ft diameter; ft liquid depth; <br /> ft to residence; ft to w ft to property line; <br /> ft to ordinary high water of lac tream; ft to edge of slopes <br /> greater than se ge pit inlet pipe-ele tion ft; bottom of <br /> seepage pit elevation ft. <br /> (10) SEEPAGE BED SIZE: -t- ft width; �#t length; ( - tile depth; <br /> _7z li.neal feet tile; 30 ft to residence; ?, ' ft to well ; 16 ft to lot or <br /> property line; �/� ft to ordinary high water mark of lake or stream; ZV_ ft to edge <br /> of slopes greater than 20% falling away toward lakes, water courses or drainage ditches <br /> Elevation of tank discharge line entering bed 9 74'3 '" ft <br /> 11 SEEPAGE ii , jai length or seepage trench ft; width ft; <br /> tile depth ft; ft to well ; nary high water mark of <br /> lake or stream; ft to edge greater than 20% falling away toward lakes , <br /> water courses or drainage di a evation discharge line entering seepage <br /> trench ft <br /> (12) Has system been installed in area indicated on EH 115? 5JYES D NO <br /> (13) Has system been installed in floodway? DYES Can Floodplain? DYES R NO <br /> DILHR-SBD-6095 N.05/80 <br /> Signature of Inspector: <br />