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REPORT ON INSPECTION OF SANITARY PERMIT # 4� <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Ins ection <br /> 1711zvl/x)_1 <br /> / T' a a Inspection <br /> Nape, Ptarress icErnse NO. OT insraning Plumber <br /> T3--INSTALLATION CONSISTS OF: !7eepage <br /> pti Tank ❑ Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit Bed ❑ Holding Tank [:] Fill System <br /> BENCHMARK: (Permanent referencePoint) escri e: <br /> Elevation of vertical reference point: Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: <br /> (6)SEPTIC TANK: Manufacturer:j Liquid Capacity: 7�W 5W <br /> Tank Inlet Elevation: Tank Outlet Elev: <br /> # ft to lot or property line: # ft to wel l <br /> M 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? []YES ❑NO Wired? ❑YES [—]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? ❑ YES []NO; Wired? ❑YES ❑ NO; <br /> Locking device on cover? [] YES ❑ 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 /> (10) SEEPAGE BED SIZE: j );r _ ft width; ft length; g_:�,2 ile depth; <br /> �> 1 i.neal feet tile; ft to resi dencO� ft to well f�cG� �ft to lot 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 line entering bed 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? EYES [] NO <br /> (13) Has system been installed in floodway? []YES ONO Floodplain? ❑YES SNO <br /> DILHR-SBD-6095 N.05/80 <br /> Signature of Inspector:�-7-�-' <br />