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REPORT ON INSPECTION OF SANITARY PERMIT # ( //) <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Ins section <br /> ) 7 • 2 <br /> me� ��° 1Pek�'� y T. e o Inspection <br /> A,ddre iii e No. of Instal ling Plumber <br /> �i?� 1 3 f - <br /> (3)INSTALLATION CONSISTS OF: eptic Tank ❑ Seepage Trench ['Dosing Chamber <br /> ❑Seepage Pit ‘age Bed ❑ Holding Tank ❑ Fill System <br /> (4)BENCHMARK: (Permanent reference Point) Describe: <br /> •, 6'; lc / me.',", <br /> Elevation of vertical reference point: 571;4A7,- 7 1 %{ 7s( `Slope at site: . 2 , <br /> (5)MATERIAL AND DEPTH OF SEWER:. ,, ,..47" U .t:/.. ef 1 :.:*< <br /> 6 SEPTIC TANK: Manufacturer: ; Liquid Capacity: / ' / <br /> Tank Inlet Elevation: i 'f' Tank Outlet Elev: /7-'-/ <br /> # ft to 1 of or property 1 i ne: V # ft to wel 1 :,,;:!Z ' <br /> ,,YZ'j--- <br /> (7)DOSING <br /> -•'(7)DOSING TANK: Manufacturer: # of gallons : <br /> # of gallon pump set for a cycle gallons ; total capactiy of distribution <br /> lines gallon; size of pump head; gallon per minute ; <br /> horsepower ; brand name of pump and model number • <br /> Is the warning device installed? EYES ❑NO Wired? DYES ❑NO <br /> (8) HOLDING TANK: Manufacturer ; # of gallons , <br /> construction ; depth to the cover ft; If septic tank is <br /> being used are baffles removed? ❑ YES ❑ NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? 0 YES ❑NO; Wired? OYES ❑ NO; <br /> Locking device on cover? ❑ YES 0 NO; Diameter of vent and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; <br /> ft to residence; ft to well ; ft to property line; <br /> ft to ordinary high water mark of lake or stream; ft to edge of slopes <br /> greater than ; seepage pit inlet pipe-elevation ft; bottom of <br /> seepage pit elevation ft. <br /> t <br /> (10) SEEPAGE BED SIZE: ,� ;' ft width; ft length; .:- - the depth; <br /> / 5 1' lineal feet ti 1 e; ,_.21731 ft to residence; \j"//Y ft to well ; `mc' ft to 1 of or <br /> property line; ft to ordinary high water mark of lake or stream; ft to edge <br /> of slopes greater than 20% falling away toward lakes, water courses or drainage ditches <br /> Elevation of tank discharge l i ne entering bed _;2 ,rte' ,-- ft. <br /> (11) SEEPAGE TRENCH: Total length of seepage trench ft; width ft; <br /> tile depth ft; ft to well ; ft to ordinary high water mark of <br /> lake or stream; ft to edge of slopes greater than 20% falling away toward lakes , <br /> water courses or drainage ditches; elevation of tank discharge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH 115? EIYES ❑ NO <br /> (13) Has system been installed in floodway? DYES ONO Floodplain? ❑YES ® NO <br /> DILHR-SBD-6095(N.05/80) <br /> Signature of Inspector 1Z ; , �,t <br />