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REPORT 'ON INSPECTION OF SANITARY PERMIT # ' 1, . <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Ins ection <br /> kNwl , Ti o Inspection <br /> Name, Ad res icense NO. OT installing Plumber <br /> ,C) <br /> 3 INSTALLATION ONSISTS OF: E3-Septic Tank ❑ Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit eepage Bed ❑ Holding Tank [] Fill System <br /> B N ermanen re erence in Describe: <br /> I It <br /> f ti <br /> Elevation of vertical reference point: / C L> > Slope at site: r; <br /> (5)MATERIAL AND DEPTH OF SEWER: ill_ / z <br /> (6)SEPTIC TANK: Manufacturer: W G P Liquid Capacity: 5 G <br /> Tank Inlet Elevation: �, ,Sj' Tank Outlet Elev: Gl 7 '/ 0 <br /> # ft to lot or property liner _S # ft to well : �,. -- - <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 1w -- 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 EINO; ft from residence; <br /> ft from well ; ft from' pnnp�ly line. Type of warning device <br /> Is the warning device installed? ❑ YES -'----- []NO; Wired? ❑YES ❑ N0; <br /> Locking device on cover? __-0 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; f t"t.Q well ; ft to property line; <br /> ft to ordinary high water mar -- 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: 1 ,7_+ ft width; ft length; 36 the depth; <br /> 75-1i.neal et ti 1 e; <br /> .3 0ft to residence; ft to well ; 30 ft to lot or <br /> property lined ft to ordinary high water mark of lake or stream; 'Alh 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 27 4 ., ft. <br /> 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; <br /> tile depth ft; '�to well ; ft to ordinary high water mark of <br /> lake or stream; ft to edge slopes, greater than 20% falling away toward lakes , <br /> water courses or drainage ditches; eley on of tank discharge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH 115? [3YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES ONO Floodplain? []YES ® NO <br /> DILHR-SBD-6095 N.05/80 <br /> Signature of Inspector: 4 3 / 16D <br />