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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,W 153707 <br /> CONVENTIONAL El ALTERNATIVE Slale Plan 1.D.Number <br /> IH a..Ign.al <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NA F PERMIT HOLDER. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE. <br /> BENCHMARK ere,ence oomll DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.'. CST REF.PT.ELEV. <br /> manem <br /> Namenl IumOer. MP/MPRSW N. Courcy Saneary Permit Number. <br /> 03c 60/86 is ors <br /> SEPTIC TANK/ NK: <br /> MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> _ I/ PRIyOVFIDED'. PROVIDED. <br /> 77 Jinn .1zf LIVES ❑NO ❑VES ❑NO <br /> BEDDING. VENT DIA.. VENT MAIL. HI(iM WATER NUMBER OF ROAD: PROPERTY W BV ILOING j­1; ­­TH <br /> ALARM FEET FROM ./.f LI" �� AR mLET <br /> 4T <br /> OYES ®NO C' DYES ONO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIOUH]OAPACIly PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED. <br /> OYES ❑NO DYES <br /> END EYES ONO <br /> ITO <br /> GALLONS PER CYCLE: PUMP ANDCONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENTAIR <br /> FflESH <br /> (DIFFERENCE BETWEEN FEET FpOM uNE AIR INLET. <br /> PUMP ON AND OFF) ❑VES LINO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING, <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH. LENGTH NO.OF DISTR PIPE SPACING COVER INSIDE CIA RPITS LIDUIO <br /> BED/TNWGH TRErvcH Es MA ERIAL: PIT DEPTH. <br /> DIMENSIONS yt- W��y <br /> GRAVEL DEPTH FILL OEPTM OISTH PIPE DISTR PIPE DISTR.PIPE MATERIAL. NO "'5 <br /> NUMBE OF PROPERTY //KI BUILDING. V NT TO Ffl ESH <br /> BELOWPIPES ABOVE COVER ELEV INLET ELEV END. PIPES LINE. /,K AIR INLET <br /> �ryl( n FEET FROM !' F <br /> , �' � ' G//' TY - -3 NEAREST �l/ X2 J � <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <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 /> OYES ONO <br /> SOIL COVER TEXTURE PERMANENT MARKER$ OBSERVATION WELLS <br /> DYES ONO ❑YES ❑NO <br /> DEPTH OVER TRENCH'BED DEPTH OVER TRENCH:BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGE5 <br /> EYES <br /> ❑NO ❑VES ❑NO EYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH. NO.OF LATEflAL 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 D15TR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV. ELEV. DIA. ELEV.. PIPES DIA <br /> - <br /> ELEVATION AND <br /> Df$TRIOUTION SPACING HOLESIZE HOLEDRILLEDCORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> DYES <br /> -]NO EYES <br /> -]NO <br /> COMMENTS: <br /> PER MANENTMARKERB: OBSERV ATION WELLS: NUMBER OF LArOE ERTV WELL. BUILDING. <br /> FEET FROM <br /> ❑VES ❑NO ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> S19NPTIYRE. TITLE. _ <br /> ! p tl7ttt c-cLC <br /> DILHR SBD 6710 (8.01/82) �- <br />