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q--2 co Ct a UU �rWr i <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELrTIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 ��' State Plan LD.Number. <br /> _ CONVENTIONAL L-1ALTERATIVE (nass,nee) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER: ADDRE:i OF PERMIT HOLDER: /p to �/Z(j vl S,G INSPECTI N ATP. <br /> Qa.)C �1��rnanrl 0400 S.K.Mnort, CA <br /> BENCHM ARK IPermanen[reference point)DESCRIBE IF DIFF ENT FROM PLAN: REF. ELEV.: CST REE PL ELEV.'. <br /> \"___1 ✓1es1- r t k S�T/riL /60 <br /> Name of Plumber: MPIMPRSWNo County Sanitary Permit Number. <br /> too �c i <br /> in ('Lm s <br /> SEPTIC ANK/HOLDING TANK: <br /> MANUFACTURERLIQUID CAPACITY: TANK INLET ELEVr. TANKOUTLETELEVa WARNINGLABEL LOOKING COVER <br /> 9/ / / PROVIDED: PROVIDED'. <br /> (O /Y6w YES ❑NO ❑YES NO <br /> BEDDING: VENT DIA.: VENT MATL'. HIGH WATER NUMBEfl OF R": PROPERTY WELL: BUILDING: VENT TO ESH <br /> tl ALARM'. FEET FROM © / LINE: / ,��I AIR INLET: <br /> []YES NO T ❑YES NO NEAREST—� <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING'. LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING <br /> ARMPROVIGLABEL ED PROVIDED: <br /> COVER <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 depthof plowing FORCE LENGTH'. DIAMETER'. MATERIAL AND MARKING: <br /> or excavation. (It soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH: NO.OF DISTR.PIP SPADING: COVER INSIDEDIA' If PITS: LIQUID <br /> BED/TRENCH la TRENCHES: �� M ERIAL: PIT r4 <br /> BELOW <br /> D �'-•— <br /> DIMENSIONS "OJ" <br /> GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR.PIPE DISTR PIPE MATERIAL: N DISTR. NUMBER OF PROPERTY WELL'. BUILDING: VENT TO FRESH <br /> BELOW P`fES'. ABOV fi-O�F3' EL .JNL T: E SENO'. ��� PIPES: FEET FflOM LINE: 5 AIR /ETj <br /> OV /V_ 5 f]i�3 7 NEAREST—* y / t <br /> MOUND SYSTEM: *60 <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 /> SOIL COVER TEXTURE' PERMANENT MAR KERS: OBSERVATION WELLS'. <br /> ❑YES ❑NO I ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TR ENCH/BED DEPTHS OF TOPSOIL SODDED: SEEDED: MULCHED: <br /> CENTER: EDGES: <br /> ❑YES LINO ❑YES ❑NO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: NRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> '. <br /> ELEV.'. ELEVr. DIA.. ELEV.I PIPES: DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLESPACING: DRILLED CORRECTLY: COVER MATERIAL'. VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> [--]YES L1 NO ❑YES ❑NO <br /> PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING. <br /> COMMENTS: FEET FROM LINE <br /> ❑YES ❑NO ❑YES ❑NO NEAREST <br /> aK 9 <br /> ffooi&5eo tee__ erg& 5 /e- &ru0e11 frese'"I <br /> f <br /> 7,;- <br /> Old" <br /> tainm county file for audit. <br /> Sketch System on ` <br /> Reverse Side. SIGNATURE'. TIT '. <br /> SBD-67101R.06/88) <br />