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r p J REPORT ON INSPECTION OF- SANITARY PERMIT # <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection <br /> /� dam/ <br /> Nam , ress, icense o. o ns a ing Pl umbe ��' T�e of nspection <br /> 17 <br /> 3 INSTALLATION CONI S OF: ❑ Septic Tank ❑ Seepage Trench ❑Dosing Chamber <br /> ❑Seepage. Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System <br /> B ermanen re eren-c-e-P.,,in Describe: <br /> Elev of vertic- al reference point: ( 60 Slope at site: °lo <br /> (5)MATERIAL AND DEPTH OF SEWER: <br /> (6)SEPTIC TANK: Manufacturer: (y G p Liquid Capacity: 7g-� <br /> Tank Inlet Elevation: �,Q Tank. Outlet Elev: 9'7`J� " <br /> # ft to lot or property line: :30 � # ft to well : <br /> (])DOSING TANK:- Manufacturer: - # of gallons : - <br /> # of gallon pump set for a cycte� - gallons-; total capactiy of distribution <br /> lines - gallon; size off Pum— p head; gallon per minute c <br /> horsepower brand .of puma and model number <br /> Is .the warning device installed[-]YES ❑NO -,Wired? [-]YES ❑NO <br /> 8 HOLDING TANK: Manufacturer # of gal Ions, <br /> construction depth to the cover - ft; If septic tank is <br /> being used are baffles removed? JPO;- ft from residence; <br /> ft from well ; fro operty line. Type of warning device - 1 <br /> Is the warning device installed? ❑ YES NO; Wired? []YES ❑NO; <br /> Locking. device on cover? : ❑YES ❑ NO; Diameter of vent and material <br /> Distance from building to vent . <br /> .(9) .SEEPAGE PIT SIZE: #`of pits; -- diameter; ft liquid depth; - <br /> ft to residence; ft to well • ft to property line; <br /> ft to ordinary high water marl k oor stream; ft to edge of slopes <br /> greater than - seep pit inlet pile-elevation ft; bottom of - <br /> seepage pit elevation ft. J <br /> (10) SEEPAGE BED SIZE: t x- ft width; ft length; _?-,4/" tile depth; 1 <br /> / /0 lineal feet tile; LIIJ6 ft to residence; Z ft to well ; .5- ft to lot or <br /> property line; /O� ft to ordinary high water mark of lake or stream; SO 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 G 7 ft. - - - i <br /> 11 SEEPAGE TR : Total length of seepage tren ft; width ft; <br /> tile depth fh,ft to well • ft to ordinary high water mark of <br /> lake or stream; ft'to-ed o opes greater than 20% falling away toward lakes , <br /> water courses or drainage dit e -evati.on of tank discharge line entering seepage <br /> trench ft. -' <br /> (12) Has system been installed in area indicated on EH 115? , VES ❑ NO - <br /> (13) Has system been installed in fl oodway? ❑YES J2"O Floodplain? ❑YES _PR7NO <br /> DI LHR-SBD-6095 N. 80 <br /> Signature of Inspector: <br />