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5 C1 30 <br /> DEFARTM1 FNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LgBOA&HUMAN RELATIONS DIVISION <br /> P.0-BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 State Plan LD.Number <br /> ❑ CONVENTIONAL ❑ ALTERATIVE ptaeaigmnn <br /> �li _"Z <br /> ❑ Holding Tank ❑ In-Ground Pressure Mound <br /> NAME OF PERMIT HOLDER' ADDRESS OF PERMIT HOLDER: INSPECTION DATE'. <br /> n v,) su%Lio <br /> B MARK(Permanent reference polnn DESCRIBE IF DIFFERROM PLAN: REF.PT.ELEV.: CST REF PT.ELEV.: <br /> :5 of <br /> Nameo lumber: MPIMi; S;.'. County. Sanitary Permit Number. <br /> 5 i?St n �3ZSteq Li <br /> SEPTIC T NK/HO DIN TANK: <br /> MANUFA TUREREHIGHWATER <br /> UID CAPA ITV: TANK INLEtROAD <br /> TAN OUT TELEV.'. WARNINGLABEL LOCK(NG COVER <br /> PROVIDED: PROVIDED <br /> 4'10 <br /> SCh SC /O �� YES ❑NO ❑YES NO <br /> BEDDING'. VENT CIA.i/ VENT MATIF NUMBEflOF PROPERTY WELL BUIL NG: VEFEET FROM❑YES NO C�ef.SNO NEAREST 0 5 p <br /> DOSING HAMBER: <br /> MANUFACTURER BEDDING: LIQ UID CAPACITY: PUM MODEL PUMP/SIPHONANUF CTURER: WARNINGLABEL LOCKING COVER <br /> VI- 1111//��(e 9 PROVIDED: PROVIDED'. <br /> uj�ger DYES NO �0 G� YES ❑NO XYES E]NO <br /> ALLONS PER CYCLE' PUMP ANO CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING: VENT (Lit-iii <br /> (DIFFERENCE BETWEEN FEET FROM LINE / AIR INLET <br /> PUMP ON AND OFF YES ❑NO NEAREST---ji > <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth otplowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING <br /> / <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN 30�o 311 <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> BEDITRENCH WIDTH. LENGTH: TNO OF RENCHES: DISTR.PIPE SPACING' MOTERIAL INSIDE DIA.: ifi LIQUID <br /> PIT DEPTH'. <br /> DIMENSIONS <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: N0.DISTR. NUMBER OF PROPERTY WELL BUILDING: VEN TO FRESH <br /> BELOW PIPES: ABOVE DOVER: ELEV.INLET: ELEV.ENO: PIPES'. FEET FflOM LINE: AIR INLET'. <br /> NEAREST�i <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE ADIAGRAM 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 MARKERS: OBSERVATION WELLS', <br /> C(IQIi ^ 1.6: s6•es�l/ (Qa YES El NO ES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCHIBED DEPTHSOF TOPSOIL: SODDED: SEEDED: MULCHED: <br /> CENTER: EDGES, <br /> 1['i I.0 ❑YES EYINo YES ENO EYES KNO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH'. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: <br /> DIMENSIONS J 8 r TRENDS: C 7// /r A_ <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIALS MARKING. <br /> ELEVATION AND E •� ELtr'X DIA'�J y/ EL J/7 J /y S�q PIP& DIA.: `/�Y <br /> DISTRIBUTION 0 f1 J r 3 J I�'a <br /> HOLE SIZE HOLE SPACING: DRILLED CORRECTL Y COVER TERIA^L'' VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION ' ILI p l�Ab APPROVED❑YES Ll NO <br /> 8 YES 17NO u <br /> PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL'. BUILDING' <br /> COMMENTS: FEETF,pROM yap /�I y /p(/ <br /> YES ❑NO <br /> /' 1 YES ❑NO NEARBSr 0 J' <br /> 3 EAS ii y�l <br /> 3. a. <br /> 7 <br /> Gn di bw•ff <br /> �wnP o iy (P Bin= a.ov <br /> i <br /> Y Retain in county file for audit. <br /> Sketch System on <br /> Reverse Side. SIGNATURE: TITLE <br /> SBD-6710(R.06/88) <br />