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f)-( _ X9 1 :&0 <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> BUREAU OF PLUMBING <br /> P.O.BOX 7x65 <br /> MADISON,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE <br /> sta aPlanl o.N mbar, <br /> Kiding <br /> ❑ Tank ❑ In-Ground Pressure ❑Mound <br /> NA OF PERMIT HOLDER: A^D�ORESS OF PERMIT�OLDER'. �^ INSPECTI DATE: <br /> / ! 1 Z <br /> BENCHMARK IP nem r nce point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT,E LEV.: CST REF PT.ELEV <br /> Nemeof Pl ber. 1 MPPe/�M�PRBW�N..'. County' Sanitary Pa mit Number <br /> SEPTIC TA K/HO V <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.'. TANK OUTLET E LEV.. WARNINGLABEL LOOKICK I NO OVER <br /> 5 <br /> PROVE <br /> FIND DYES 10 NO <br /> BEDDING: VENT DIA.'. n LET <br /> VENT MAI HIGH WATER NUMBER OF ROAD: PROPERTY W LL: BUILDING'. VVERNNTO FRESH <br /> NE' <br /> DYES NO ! 1 AL❑VES ❑NO NEARESTFEET FROM <br /> I J�� 'Z' ZC� <br /> G!4 <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY'. PUMP MODEL: PUMPISIPHON MANUFACTURER: PARVADLABEL LOCKING <br /> CKNG LIVER <br /> PROVID <br /> DYES ❑NO YES ❑NO DYES <br /> ❑NO <br /> PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY IWILL BUILDING: AIR INLET <br /> ENT TO FRESH <br /> GALLONS PER CYCLE: LINE <br /> (DIFFERENCE BETWEEN FEET FROM <br /> PUMP ON AND OFF) Dy <br /> ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moistureat the depth of plowing LErvGTH. GIAMErItR. MATE IAL AND MARKING <br /> FORCE <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until <br /> MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH: LENGTH: / NO.OF DISTR PIPF�SPACING: COVER INSIDE DIA.'. *PITS'. LIQUID <br /> BED/TRENCH i TRENCHES'. / MA IAL: PIT DEPTH'. <br /> DIMENSIONS (� ,� (- � � <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DIB NUMBER OF PROPERTY WELL: BUILDING: V NT TO fRESH <br /> BELOW PIPES; ABOVE COVE ELEV.INLET'ELEV.END: _ LINE' / - AIR.INL Lam_ <br /> PIPES, FEET FROM L y �� ,j 17 <br /> NEAREST— v <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 /> ❑YES ❑NO <br /> PERMANENT MARKE RS'. OBSERVATION WELLS <br /> OIL COVER rE%TURF'. <br /> DYES ❑NO EYES FIND <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCHIBEG DEPTH OF TOPSOIL SODDED' SEEDEtr. MULCHED'. <br /> CENTER. EDGES: <br /> ❑VES ❑NO DYES EINO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL E EPTH ABOVE COVER'. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIP E MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTR BUTION PIPE MATERIgL&MARKING. <br /> ELEV.'. ELEV.: DIA.: ELEV.: PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTIONHOLE SIZE HOLE SPACING: GRILLED CORRECTLY. COVER MATERIAL VERT CALLIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLAN <br /> YES ❑NO DYES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL:LINE <br /> BUILDING. <br /> FEET FROM : <br /> DYES 1:1 NO ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audi t. <br /> Reverse Side. SOND E ITLE: ^ <br /> 1 <br /> DI LHR SBD 6710(R.01/82) <br />