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_ O I <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.Box 796s ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 State Plan I.D.Number. <br /> CONVENTIONAL ❑ ALTERATIVE (it assigned) <br /> Ll Holding Tank E:1 in-Ground Pressure El Mound <br /> NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER. INSPECTION DATE'. <br /> BENCH h DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.'. CST REF.PL ELEV.: <br /> Name of Plumber MP/MPRSW No County. Sanitary Permit Number'. <br /> 3asC� jc 1137T <br /> SEPTIC TANIK/HOIL DING TANK: <br /> MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.'. TANKOUTLETELEV.: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> ❑YES ❑NO ❑YES ❑NO <br /> BEDDING: VENT DIA VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL'. BUILDING. VENTTOFRESH <br /> ALARM'. FEET FROM LINE', AIR INLET. <br /> ❑YES ❑NO [-]YES ❑NO NEAREST--- <br /> DOSING <br /> EARESTDOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIQUID CAPACITY: PUMP MODEL'. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED'. <br /> ❑YES ❑NO ❑YES ❑NO DYES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBEROF PROPERTY WELL BUILDING VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET: <br /> PUMP ON AND OFF ❑YES [:1NO NEAREST <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER'. MATERIALAND MARKING. <br /> or excavation. (It soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> BED/TRENCH WIDTH. LENGTH NO OF TRENCHES' DISTR.PIPE SPACING: MATERIAL PIT INSIDE DIA.: }J PITS DEPTH <br /> DIMENSIONS <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE I DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> BELOW PIPES. ABOVE COVER: ELEV.INLET I LEV.END. PIPES. FEET FROM LINE: AIR INLET: <br /> NEAREST—� <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVER ITEXTURE: PERMANENT MARKERS. OBSERVATION WELLS: <br /> ❑YES ❑NO ❑YES [:1 NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED' SEEDED: MULCHED'. <br /> CENTER: EDGES. I <br /> —L ❑YES ❑NO _ E]YES El NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH'. NO OF LATERAL SPA Q NG'. GRAVEL DEPTH BELOW PIPE: ILLI.DEPTH ABOVE COVER <br /> TRENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING. <br /> ELEVATION AND ELEV.: ELEVI. DIA. ELEV: PIPES. DA. <br /> DISTRIBUTION HOLE SIZE'. HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES LINO ❑YES LINO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. <br /> FEET FROM LINE <br /> ❑YES ❑NO ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIGNATURE'. TITLE <br /> SBD-6710(R.06/88) <br />