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REPORT ON INSPECTION OF SANITARY PERMIT # e 4 <br /> (1') Name and Address of Permit Holder Person/Persons at Site (2)Date of Insp tion <br /> 1 Ti o nspection <br /> N me, .dress, 1 ense t installing Plumber <br /> (3)INSTALLATION CO SINS OF: [Er5-- <br /> eptic Tank [' Seepage Trench ['Dosing Chamber <br /> ❑Seepage Pit epage Bed ❑ Holding Tank ❑ Fill System <br /> (4)BENCHMARK: (Permanent reference Point) Describe: <br /> Elevation of vertical reference point: Slope at site: Q <br /> (5)MATERIAL AND DEPTH OF SEWER: �� „2/_)ii /( 0K /® !a,,z-¢./yo5.4"-eor-cep--fr- <br /> (6)SEPTIC TANK: Manufacturer: /� Liquid Capy: 7, <br /> Tank Inlet Elevation: P2 " Tank Outlet Elev: 6" <br /> # ft to lot or property line: 9D/-1..,070/ c L KeZierizipew # ft to well : 3-1- z <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? DYES ❑NO Wired? OYES ❑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? 0 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 ONO; Wired? OYES ❑ NO; <br /> • <br /> Locking device on cover? DYES 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 /> (10) SEEPAGE BED SIZE: j g ft width; ,2/c ft length; 42� " the depth; <br /> —73"1 i.neal feet tile; j5 ft to residence; 7, .'ft to well ; 16/ 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? DYES ❑ NO <br /> (13) Has system been installed in floodway? DYES ['ONO Floodplain? OYES \NO <br /> DILHR-SBD-6095(N.05/80) <br /> Signature of Inspector:✓` .��� 2;,‘ , <br />