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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> — LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> NJCONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: <br /> (If assigned) <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> rtr...a...,N. �-I2,E• <br /> !� 6�, �.. ,i.�� syYb 1 -//- 711 <br /> BEN MARK(Per/m/anent reference{%�point)DESCRIBE IF DIFFERENT FROMf/�PLAN: /// Jul iVi ` e A g-�/-' �/� ��� REF.PT.ELEV.: CST REF.PT.ELEV.: <br /> .� 7 ���'' /J"�/`� f ���,C�1..s w_" r�� T wc.�!/^ !�//�_`C6M.^'rr _.�-/ 9A_Name of Plumber r D/� �'_"�MP/MP SW o. County: Sanitary Permit Number: <br /> ` c,cL�, 41 )4 Ia. -e-wy,...a....kk- 315G.51 (1iago) <br /> SEPTIC TA /HOCDtNG-T-*NI(: /�, q�Jr� <br /> MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: (.Tp :0LiE E'[EV.. WARNING LABEL LOCKING COVER ' <br /> Gjj/ y/� ql�_ (if�4 (JJVV7 PROVIDED: PROVIDED: <br /> t'V� ��� j/ � ZYES LINO OYES ENO <br /> BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF+, RQ9p:_, PROP WELL: BUILDING VENT TO FRESH <br /> �f ALARM FROM "/�l�U / JL ','� (� AIR INLET: <br /> OYES C 'NO FEET. ❑YES ❑NO NEAREST > /"L�+— t4,' 4tO L`�[� 2 / <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> ❑YES ❑NO OYES ONO OYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET` <br /> PUMP ON AND OFF) OYES ONO NEAREST---,- <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I Frvi,I . DIAMETER MATERIAL AND MARKING <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> the soil is dry enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> WIDTH: LENGT3H NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA.-. *PITS LIQUID <br /> BED/TRENCH L'/ THE CHES / MATTE A PIT DEPTH. <br /> DIMENSIJNS /a r S / 6 ✓11Gf, <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPF 1DISTR.PIPE (DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF !PROPERTY WELL BUILDING: VENT TO FRESH <br /> BELOW PIPES/. / ABOVE COVER: ELEV.INLET!ELEV.END. t� PIPES- FEET FROM LINE- f �Q 1 AIR INLET:/ <br /> 6 1 J-Z" 13 I ?r/ C 2. NEAREST--s , , ia 3 Q <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> DYES ENO <br /> SOIL COVER(TEXTURE PERMANENT MARKERS: OBSERVATION WELLS <br /> OYES ❑NO OYES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED: MULCHED. <br /> CENTER EDGES. <br /> OYES ONO ❑VES ONO OYES LINO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.: ELEV.. DIA.. ELEV.: PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> OYES ONO OYES ONO <br /> r <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: rNUMBER OF [PROPERTY WELL: BUILDING: <br /> FEET FROM III LINE: <br /> OYES ONO OYES ONO NEAREST 0 <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGN TURF: TITLE: <br /> DILHR SBD 6710 IR.01/82) /� � 4"," 0 -z g-elif --- <br />