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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY ' <br /> LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS <br /> P.O.BOX 7969 BUREAU OF h, <br /> MADISON,WI 53707 <br /> [I]CONVENTIONAL ❑ALTERNATIVE stare Plan I.D.Number <br /> Holding Tank 1:1 In-Ground Pressure ❑ (if a—goeelMound <br /> N OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER. INSPECTION DATE <br /> 3 6 chi — �— � <br /> BENCH MARK IPermanevrelrrence DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PL ELEV. <br /> Name o Plumber. ,r MPIMPRSW Nn County. SamtarV P­,,Number: <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER ^ LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER <br /> PIR�O(VES PROVIDED-'2-1600Iql�/DQD [:]NO 10YES ONO <br /> BEDDING. VENT CIA I VENT MALL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING VENT TO FRESH <br /> L/t/ ALARM FEET FROM �y / LINE <br /> r1 tv� AIR wE T. <br /> EYES ONO 7 C g� YES ❑NO NEAREST —y1 /0 /5/ 33 B•u11d yv h&4 <br /> DOSING CHAMBER: VIIIIIIllYh`�$ �R'L�A'r5r�e (/YI Ue T be /p' TG <br /> MANUFACTURER BEDDING. LIQUID CAPACI Iv 1PUME MODEL PUMP/SIPHON MA NUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED. <br /> DYES ONO [—]YES ❑NO OYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM iLINE AIR INLET. <br /> PUMP ON AND OFF) OYES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at thedepth otplowingFORCE 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 /> CONVENTIONAL SYSTEM: <br /> WIDTH. LENGTH NO.OF D6TH PIPE SPACING COVER INSIDE DIA #PITS LIOU ID <br /> BED/TRENCH TRENCHES MATERIAL: PIT DEPTH. <br /> DIMENSIONS <br /> GRAVEL DEPTH FILL UEPTM OISTfEPIPE DISTR PIPE DISTH.PIPE MATERIAL NO.DISTR NUMBER OF PROPERTY WELL BUILDING'. VNT TO FRESH <br /> BELOW PIPES ReavE COVER ELEv INLET ELEV FND PIPES FEETFROM LIrvE. AIR INLET. <br /> NEAREST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> DYES ONO <br /> SOIL COVER TEXTURE PERMANENT MARKERS. OBSERVATION WELLS <br /> ❑VES ONO [—]YES ❑NO <br /> DEPTH OVER TRENCH BED DEPTH OVER TRENCH:BED pFPiH OF TOPSOIL SOUOED SEEDED MULCHED. <br /> CENTER EDGES <br /> OYES ❑NO ❑YES ONO Ll YES ENO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH NO.OF LATERAL SP ACING. GRAVEL DEPTH BELOW P IPF FILL DEPTH ABOVE COVER <br /> BED/TRENCH TRENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE OISTRIBUT ION PIPE MATERIAL&MARKING <br /> ELEV. ELEV.' DIA ELEV. PIPES DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIF T CORRESPONDS TO APPROVED <br /> DYES [:]NO PLANS <br /> ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL: BUILDING' <br /> FEET FROM LINE <br /> DYES FIND EYES LINO NEAREST <br /> / r2tG.]lae• —moI jn., to b< 7 2U r rrvo,Tol + 4>_ <br /> d(veo O <br /> h,pof L� C(e,jkrC IC /iuw rti . <br /> KIYI dC *a 607_ <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> IIGNAT TITLE <br /> DILHR SBD 6710 (R.01/82) �� �� <br />