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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN`gELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 <br /> State Plan L0.Number: <br /> ❑ CONVENTI Ql�Nfj�L,� ❑ ALTERATIVE (if assigned) <br /> ❑ Holding Tank b�-"`l'-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER.6teve saa,$CT�_ ADDRESS OF PERMIT HOLDER: INSPECTION DATE'. <br /> rI)J 5?5?a3 _ <br /> BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN-. REF.PT.ELEV.: CST EF.PT ELEV.: <br /> i <br /> Name of Plumber: MPIMPRSW No. County: Sanitary Permit Numbe: <br /> P� 3383 Zurn&ck -- <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTUR LIQUID CAPACITY: TANK INLET ELEV I TAN UTLETELEV.: WARNING LABEL LOCKINGCOVER <br /> r, /^ PROVIDED: PROVIDED: <br /> 1 W ES O NO S ❑NO <br /> BEDDING'. VENT DIA: VENT MATL- HIGH WATER NUMBER OF ROAD' / PROPERT ELL' f BUILDING'. VENTTOFRESH <br /> �� ALARM: FEET FROM LIN ^ / AIR INLET' <br /> [:]YESO q.S� NO NEAREST— <br /> DOSING HAMBER: <br /> MA FA ER BEDDING'. LIQUID CAPACITY:LEYES <br /> MP MODEL: PUMP/SIPHON MAIryLfEEACTURER: WARNING LABEL LOCKING COVER <br /> rLr/yyR" � i � PROVIDED: PROVIDED'. <br /> uT,j"4:1 ❑YES 6N0 ��OQ //C ES r_1 NO YES 0 N <br /> ALLONS PER CYCLE: PUMCONTROLS OPERATIONAL'. NUMBER OF PROPERTY ELL: BUILDI G: VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIRI LE^ <br /> PUMP ON AND OFF ❑NO NEAREST--* �V 71�" !'C'� <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: / DIAMETER: MATERIAL AN 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 /> BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA' //PITS'. LIQUID <br /> TRENCHES: MATGRITj�� PIT <br /> DIMENSIONS r <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRES <br /> BELOW PIPES'. ABOVE COVER: ELEV.INLET: ELEV.END: PIP : FEET FROM LI / IR INLET�}'�rr <br /> rt r NEAREST 10 W <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 /> SOIL COVER TEXTURE'. PERMANENT MARKERS: OBSERVATION WELLS: <br /> ❑YES ❑NO ❑VES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCHIBED DEPTHS OF TOPSOIL: SODDED. SEEDED: MULCHED: <br /> CENTEREDGES: <br /> [DYES ❑NO ❑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 /> DIMENSIONS <br /> TRENCHES: <br /> �( <br /> MANI OLD PUSMyPI MANIFOLD DIISFTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR PIPE DISTRIBUT9N PIPE MATERIAL&MARKING <br /> . <br /> ELEVATION AND rj� ELV�ry ' /f DIA ELEV. 3� t+�//�/� PIPE DIA-I/ Ila <br /> / �o <br /> DISTRIBUTION HOLE SIZE HOLE SPACCING: DRILLED CORRECTLY: J rl -,v COVER fi ERIAL'. VER I IIUALL(LIFT CORRESPONDS TO <br /> INFORMATION ✓ - / APPROVED PL S <br /> YES ❑NO �J r C(c(-7�- YES ❑NO <br /> PERMANENTMARKERS'. OBSERVATION WELLS: NUMBEROF PROP TV WELL: BUILDING: <br /> COMMENTS: FEET FROM LINE: / <br /> YES ❑NO ES ❑NO NEAREST <br /> 9 � S te-vi,,4P�xl <br /> P� Za leg <br /> firce �in <br /> Sketch System on Blain in county file for audit. <br /> Reverse Side. SIGNATURETITLE. <br /> SBD-6710(R 06/88) <br />