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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 /> CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: <br /> III assigned) <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. ADDRESS�PERMIT HOLDER: n n INSPECTION DATE <br /> BEdeee � /�((Q3^pJCJ� ; --/ 22 <br /> H MARK(Permanent reference tl DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV... <br /> �yy"p///J� l ate` j 6e3/ <br /> Name of Plumb���pp������� / MP/MPRSW No.. County Sanitary Permit Number: <br /> /9•4%y� o3oS9 ju.I.A.4. 3/yay ( / 0374) <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: _ LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> -7 p / PROVIDED: PROVIDED. <br /> 1 I 12 `f7 " YES LINO DYES ONO <br /> BEODI G tlIBRTDIA../ 4t6410f MATL HIGH WATER NUMBER OF ROAD: PROPR77yy WE BUILDING. VENT TO FRESH <br /> ALARM ��TTT�����yyi✓cc <br /> �/- /J {� FEET FROM / LIN LAIR INLET. <br /> YES ONO ! C .!^ ❑YES ❑NO NEAREST - ��'h I --- <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIQUID CAPACI TY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES ONO OYES LINO DYES 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) DYES ONO NEAREST > <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing ,I',,,T:: ,METER 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 LENGTH , NO.OF DISTR PIPE SPACING COVER INSIDE DIA =PITS LIOUID <br /> BED NCH I ��� (/9 <br /> TRENCHES / / MATE� L PIT DEPTH <br /> DIMENSIONS L <br /> GRAVEL DEPI 'FIL DEPTH DISTR.PIPE IDISTR PIPE IDISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PROPERTY WELL - BUILDING. VENT TO FRESH <br /> BELOW PIPE. ABOVE COVER EI EV I'LE f ELEV.END A PIPES <br /> 2 FEET FROM LINE. �. '�/ / AIR INLET: <br /> 66� " yl 6 HI �! NEAREST--►1 �' .,re <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 /> DYES ONO <br /> SOIL COVER(TEXTURE PERMANENT MARKERS OBSERVATION WELLS <br /> OYES ❑NO ❑YES ONO <br /> DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES <br /> DYES ONO ❑VES ONO OYES ONO <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 DYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: (NUMBER OF PROPERTY WELL: BUILDING: <br /> 1 FEET FROM LINE: <br /> LIVES ❑NO DYES El NO LEAREST -0- <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE. TITLE. <br /> DILHR SBD 6710 (R.01/82) ;I- 4 <br />