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(o-z4-ci I _5 _-�KD <br /> Wisconsin Departmeht Of Industry, ON SITE SEWAGE SYSTEM Safety&Buildings Division <br /> Labor and Human-Relations INSPECTION REPORT <br /> P.O. Box 7969• <br /> Z"Son,WI 53707 County: fe,l ��T <br /> ONVENTIONAL ❑AT-GRADE ❑IN-GROUND PRESSURE ❑MOUND ❑HOLDING TANK <br /> XPERIMENTAL ❑NEW ❑REPLACEMENT ❑RECONNECTION ❑OTHER(SPECIFY) <br /> Permit Holder's Name: Permit Holder's Address: - <br /> �fi u �� Inspection Date: <br /> - D , � <br /> 6 ,� o/ <br /> . <br /> Bench Mark,Describe I Di erent From Ian: Parcel Tax I.D.No.(Optional) Re Pt.Elev.: CST Ref.Pt.Elev.: <br /> PI <br /> Nam MP/MPRSW No.: State Plan lD No.(If Assigned): Sanitary Permit Number: <br /> SEPTIC TANK/HOLDING TANK: <br /> Manufacturer Liquid Capacity: Tank Inlet Elev.: Tank Outlet Elev.: Warning Label Locking Cover <br /> f�� fiW' I /ASF ��, r Pro idea: Provided <br /> J",�S '✓,Y7. / -+. .t, /y., `�. Yes ❑ No ❑ Yes K No <br /> Bedding: Vent 14 Dia.: Vent Matt''l.: High Water Alarm: NUM EROF Road: Property Line: Well: Building: Air Vent: <br /> FRM <br /> El FEET No //' ❑ Yes No NEAREST-� 1 ✓ 7�1�0 /�� - � <br /> DOSIN HAMBER: <br /> Manufacturer: Bedding: Liqui Capacity: Pump Mo e: Pump ip on Manufacturer High WaterAarm Warning La a Loc ing Cover <br /> Provided: Provided: <br /> ❑ Yes ❑ No I I I ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> G aT ons Per Cyce: Pump and Controls Operations : NUMBER Property Line: Wel : Bui ing: Air Ve(dient: <br /> FEETFROM <br /> pump on and oence ff)en Yes F7 I NEARESTT­11� <br /> Vent Installed: Vent Diameter: Vent Material: FORCE Length: Diameter: Materia an Mar ing: <br /> VENT [] yes ❑ No MAIN <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing or excavation. (If soil can be rolled into a wire,construction shall cease until <br /> the soil is dry enough to continue.) <br /> DISTRIBUTION STSTEM: <br /> BED/TRENCH WIidQth Length: No.Trenches: Lateral Spacing: Cover Matgrial: Inside Dia: No.Pits: Liquid Depth: <br /> DIMENSIONS IL / _2,1 d ��- 1/7/ PIT <br /> Gravel Below Pipes Fill Above Pipe: Inlet Elev.: En Elev.: Pipe Material No.Distr.Pipes: NUMBER OF Property Line: Well: uild in� Air Vent <br /> FEETFROM / r <br /> NEAREST--� �AS�J 1 5�z <br /> ELEVATION AND <br /> Manifold Elev.: Manifold/!'Dia.: Mani old Material: No.Distr.Pipes: Distr.Pipe Dia.: <br /> i (/ <br /> DISTRIBUTION 4 '��„ 3,3V ��-_- <br /> INFORMATION Hole Size: Hole Spacing: Drilled Correctly: Permanent Markers Observation Wells: Pump Elev.: Vertical LitCorresponds To <br /> Approved Plans: <br /> Yes ❑ No ❑ Yes ❑ No I ❑ Yes ❑ No ❑ Yes ❑ No <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check 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 /> IL COVER Texture: Permanent Markers: Observation Wells: <br /> Yes ❑ No I ❑ Yes ❑ No <br /> Depth Over Trench Bed Center: Depth Over Trench Bed Edges: Depths OTopsoil. Sodded: Seeded: Mulched: <br /> ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS:(Sketch System On Reverse Side) <br /> vv <br /> lef <br /> �(��f hI L � L 6ai yLYt'�j <br /> �,Z h a <br /> Signature: nle: <br /> (Keep a copy n your file for audit) <br /> SBD-6710(R 09/90) <br />