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I(�� <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON.WI 53707 State Plan I.D.Number. <br /> ❑ CONVENTIONAL El ALTERATIVE (if <br /> assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PEPMIT HOLDER- ADDRESSOF PERMITHOLDER _1 INSPECTION DATE <br /> j <br /> Sl( oaV\ / <br /> BE MARK IPermanenl r fer ZP Inp D C IBE IF DI FE FROM PL N REE PT.ELEV.. GST EF.PT.ELEV.- <br /> e 2/e✓a �rI 5lv 077 <br /> Name of Plumber. MPIMPRSW NO.'. County. Sanitary Permit Number <br /> s . <br /> .1(_ (�)lc 32Q� l2� �6 <br /> SEPTICTANKIHOL TAN : <br /> MANUFA'TURE.F:, ,I �/ /� LIQUID CAPACITY: TANK INLET ELEV.'. TANK OUTLLETT}ELEV.. WARNING LABEL LOC KINGCOVER <br /> �J^�yA'nn(k/ /U ft'Ifllhokdt PRo YES ❑NO PROVIDED O <br /> BEDDING. VENT DIA.' VENT MAT HIGH WATER NUMBER OF ROAD'. �/ PROPERTY WELL'. BUILDING. VENTTO FRESH <br /> II ALARM. FEET FROM /l LINE AIR wLET- <br /> L� 7 YES NO ` ❑YES ❑NO NEAREST 6 V C> k <br /> DOSIN H El <br /> MANUFACTURER'. BEDDING'. LIQUID CAPACITY: PUMP MODEL PUMP/SIPHON MANUFACTURER- WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> _ ❑YES ❑NO ❑YES ❑NO ❑YES [:]NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL: BUILDING'. VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET'. <br /> PUMP ON AND OFF E]YES [:1NO NEAREST—♦ <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH'. DIAMETER: MATERIAL AND MARKING. <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> C VENTIONAL SYSTEM: <br /> WIDTH`. LENGTH NO.OF DISTR PIP SPACING'. COVER INSIDE DIAL. pPIT$: <br /> BE SIONSRENCH / / TRENCHES M RIA PIT DEPTH'. <br /> ENSIGNS <br /> 644 <br /> GRAVEL DEPTH FILI CFPTH MTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR. NUMBER OF PROPERTY WELL BUILDING' VENTTO FRESH <br /> BELO f,IPES AB01 V Rl ELEV.INLET. ELEV.END: PIP S. FEET FROM LINE'. AIR INL T: <br /> IIALad NEAREST�� <br /> MOUND SYS M: <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 /> SOIL COVER I TEXTURE. PERMANENT MARKERS OBSERVATION WELLS: <br /> ❑YES ElNO ❑YES [:I NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED' SEEDED: MULCHED. <br /> CENTER. EDGER: <br /> _ ❑YES ❑NO L-1 YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH'. LENGTH' NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> TRENCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: <br /> ELEV' ELEVr. DIA.'. ELEV.' PIPES. DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE'. HOLE SPACING'. DRILLED CORRECTLY: COVER MATERIAL' VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES LINO ❑YES ❑NO <br /> PERMANENT MARKERS' OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING: <br /> COMMENTS: FEET FROM❑ <br /> m 7:1LINE' <br /> / YES NO ❑YES ❑NO LNEARE57—► ,P 1 <br /> -Z _3DAE 7- 57 <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIGNATURE / TITLE <br /> SBD-6710(R.06/88) (L� <br />