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I(- <br /> 130 <br /> Wisconsin Department Of Industry, ON SITE SEWAGE SYSTEM Safety&Buildings Division <br /> Labor and Human Relations INSPECTION REPORT <br /> P.O. Box 7969 <br /> \Maiclison,WI 53707 County: (/' o � <br /> CONVENTIONAL FIAT-GRADE El IN-GROUND PRESSURE ❑MOUND El HOLDING TANK <br /> XPERIMENTAL ❑NEW ❑REPLACEMENT ❑RECONNECTION ❑OTHER(SPECIFY) <br /> Permit Holder's Name: Permit Holder's Address:17cl S e,- , Inspection Date: <br /> �s e Bench Mark,Mark,Describe If Di erent From Plan: Parcel Tax J.No.(Optional) Kel.Pt.Elev.: CST Rel.Pt.Elev.: <br /> Plu bis Na e: MP/MPRSW No: State Plan ID No.(If Assigned): Sanitary Permit Number: <br /> a � 5 <br /> SEPTIC TANKMOLDING TANK: <br /> Manufacturer: Liquid`Capacity: Tank Inlet Elev.: Tank Outlet Elev_: WarnivrIng Label Locking Cover <br /> WC Jv _0 6 / ✓• 5.7 Pr Yesd� No Prot <br /> Ej YesdjdNo <br /> Bedding: Vent Dja.: Vent MLptr'L:. High Water Alarm: NUMBER OF Road: / Property Line: Well: Building: Air Vent: <br /> ❑ Yes No H C'Q�I�C.0 ❑ Yes o NEAREST /60 �'aS' p1S pZ/ �7� <br /> DOSING CHAMBER: <br /> Manufacturer: Beding: Liqui Capacity: Pump Mo e: Pump/Siphon Manufacturer Hig WaterAarm Warning Labe Locking Cover <br /> Provided: Provided: <br /> ❑ Yes ❑ No 0 Yes ❑No 1 ❑Yes ❑No ❑Yes ❑No <br /> Ga ons Per­CyePump and Controls Operations : NUMBER Property Line: We Bui ing; Air Vent: <br /> (difference between FEET FROM <br /> pump on and off) F1 Yes No NEAREST <br /> - <br /> Vent Installed* I Vent Diameter: Vent Material: FORCE Lengt Diameter: Materia M <br /> an ar ing: <br /> VENT 0 Yes ❑ No MAIN <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing or excavation. (If soil can be rolled into a wire,construction shall cease until <br /> the soil is dry enough to continue.) <br /> DISTRIBUTION STSTEM: <br /> BED/TRENCH Width: Length: No.Trenches: Lateral S acing: Cover ater`ial: Inside Dia: No.Pits: Liquid Depth: <br /> DIMENSIONS 1�I OZp/ _)/ Vj ra((lU PIT —�- �v - <br /> Gravel Below PipesFill AboveFEET FROM <br /> Pipe: Inlet Elev.: En Elev.: Pipe Material No.Distrr..Pipes: NUMBEROF Property Line: Well: uddiinng: Air <br /> VentA z /1 : <br /> y 9 . .O 9_.046 RsEma7d NEAREST—Ill <br /> Manifold Elev.: Manifold Dia.: Manifold Material: No.Distr.Pipes: Distr.Pipe Dia.: <br /> ELEVATION AND q <br /> DISTRIBUTION 7 L� �D 3 <br /> INFORMATION Hole Size: Hole Spacing: Drilled Correctly: Permanent Markers Observation Wells: Pump Elev.: Vertical Lift Corresponds To <br /> EJ Yes ❑ No E] Yes <br /> ❑ Approved Plans: <br /> No ❑ Yes ❑ No ❑ Yes ❑ No <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicularto Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrowsthrown unslope mound systemsto makecertain that it ON REVERSE SIDE. SHOW <br /> ❑ Yes ❑ No meets the criteria formedium sand. ELEVATIONS MEASURED. <br /> SOILCOVER Texture: Permanent Markers: Observation Wells: <br /> ❑ Yes ❑ No ❑ Yes ❑ No <br /> Depth Over Trench Bed Center: Depth Over Trench Bed Edges: Depths O Topsoil: Sodded: Seeded, Mulched: <br /> ❑ Yse—s ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS:(Sketch System On ReverseSide) �� ` p5�/ / / kSQ <br /> SP�TiC Ilk � I1 -r/OmF-FQ <br /> 7 0K fle -S',95 � 6 <br /> D� JVO <br /> N l <br /> DPS - �• �K `� <br /> Signatur Title: <br /> SBD-6710(R.09/90) (Keep a copy in your file for audit) <br />