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DEPARTMfnNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SIS <br /> MADISON,WI 53707 OFFICE OF DIVISION CODES&APPLICATION <br /> State Plan I.D.Number. <br /> CONVENTIONAL ❑ ALTERATIVE (if assigned) <br /> EJ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF E MIT HOLDER: ADDRESS OF PER MIT HOLDER' /� iC I INSPECTIO'� 0, E: <br /> / , c <br /> BENCH MAHK(Perman/Ae�nteterenc point)DESCRIBE IF DIFFER%NT FROM LAM REF.PT.ELE .: CST REF.PT.ELEV.: <br /> S/T/�G r Ta Q dk /c Quo �dD <br /> Name of Plumber' MP/M RSW No.: County: Sanitary Permit Number: <br /> " 3 r ia s�Ct <br /> SEPTIC TANK/HOLDIN TANK: <br /> MANUFACTURER) � LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLETELEV.: WARNING LABEL LOCKING DOVER <br /> 11 / (�Cf 75b f - 77 PROVIDED' PROVIDED: <br /> W `r YES ❑NO ❑YES NO <br /> BEDDING: VENT DIA.: I/ VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING' VENT TO FRESH <br /> .y- ALARM: FEET FROM LINE; AIR INLET <br /> ❑YES NO �S I ❑VES O NEARE57—♦ �! <br /> DOSING CHAMBER: <br /> MANUFACTURER' BEDDING: LIQUIOCAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER' WARNING LABEL LOCKINGCOVER <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 ❑YES ❑NO NEAREST—♦ <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING'. <br /> or excavation. (11 Soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIOTM: LENGTH' NO.OF GISTS.PIPES ACING; COVER <br /> BEDI7RENCH / INSIDE DIA.: M PITS LIQUID <br /> 2 / TRENCHES: MAT "IAL: <br /> DIMENSIONS / `7 �j � PIT <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PE TY WELL: BUILDIN VENT T FRESH <br /> BELOW P PES: ABOV C yER' ELEV.INLET: L V E ` PIPES' LINE' <br /> 'O S{oJ r�7 NEAREST�� S/ 7SD� AIR INLET:/ <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicularCheck 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: <br /> PERMANENT MARKERS: OBSERVATION WELLS; <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED ❑YES ❑NO ❑YES F-1 NO <br /> SEEDED' MULCHED- <br /> CENTER: EDGES: <br /> ❑ ❑VES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: ❑YES ❑NO VES r-1 NO <br /> BED/TRENCH WIDTH: LENGTH: NO OF LATERAL SPACING' GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER <br /> DIMENSIONS TRENCHES: <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEVATION AND ELEV. ELEV.: DIA.: ELEV.' PIPES' DIA: <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING DRILLEDCORRECTLY: <br /> INFORMATION COVER MATERIAL: VERTICAL LIFTCORRESPONOSTO <br /> APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'. <br /> FEET FROM LINE. <br /> n ❑YES ❑NO ❑VES ❑NO NEAREST--11I <br /> IUo(A1�� g/hz 12.11 DPt4a dier= <br /> `feu' O ` 63 <br /> fl OF -I - S7�v <br /> PWAtrkd _r'l � <br /> O&J Mone- isnf-&- 6wr�i�a�. /rzwo�s ���if. <br /> u6)S7/racA& re4cJ64 ;re <br /> f is @ S �;xee^ s6pif o/lertrcc <br /> /^G�kvL C 561/S - <br /> Sketch System on Re ncountyfilefor dit. <br /> Reverse Side. SIGNATURE: – _TITLE' <br /> SBD-6710(R.06/88) <br />