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REPORT ON INSPECTION OF SANITARY PERMIT # <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Datef Insp c ion <br /> me, ess, i, ense Q. oInstalling plumber ar Tim of nspection <br /> J <br /> (3)INSTALLATION 009VSTS OF: ept'c Tank ❑ Seepage Trench ❑Dosing Chamber <br /> ❑Seepage Pit eepa a Bed ❑ Holding Tank [] Fill System <br /> B ermanen re erencePoint) escri Fe. <br /> Elevation of vertical reference point: -.]°'z Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: , <br /> (6)SEPTIC TANK: Manufacturer: Liquid Capacity: <br /> Tank Inlet Elevation: 3G: Tank Outlet Elev: <br /> # ft to lot or property line: ;! T ' # ft to well : 2 G <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? ❑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 [] NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? ❑ YES ❑NO; Wired? ❑YES []NO; <br /> Locking device on cover? [] 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; 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: 2 ft width; ft length; tile depth; <br /> lineal feet tile; ft to residence; t ft to wellft 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 .�- <br /> j 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? Q YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES 0 NO Floodplain? ❑YES fjNO <br /> DILHR-SBD-6095 N.0 /80 <br /> Signature of Inspector: <br />