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• REPORT ON INSPECTION OF SANITARY PERMIT # i/J 77 <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Insp ction <br /> 4-Z # ///' 1ame, ' dr ss, icense o. of installing plumber Time f nspection <br /> �/t li <br /> ,s �, eELt/�7. <br /> (3)INSTALLATION CONSI S OF: ❑ Septic Tank [' Seepage Trench ❑Dosing Chamber <br /> ❑Seepage Pit areepage Bed ❑ Holding Tank ❑ Fill System <br /> (4)BENCHMARK:(Permanent reference' Point) Describe:� , <br /> • L),-" '�'u F`fit`- ' ' IL 6� 44.A1-et <br /> Elevation of vertical reference point: ] OD Slope at site: / ' <br /> (5)MATERIAL AND DEPTH OF SEWER: 9 ' PVC - 36 `" ttom,�,, <br /> (6)SEPTIC TANK: Manufactur . Liquid Capacity: <br /> Tank Inlet Elevation: ank Outlet Elev: <br /> # ft to lot or property line: # ft to well : <br /> (7)DOSING TANK: Manufacturer: # of gallons : <br /> # of gallon pump set for a le gallons ; total capactiy of distribution <br /> lines gallon; size ump head, gallon per minute ; <br /> horsepower ; brand nam 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 , ft from residence; <br /> ft from well ; ft from erty line. Type of warning device <br /> Is the warning device installed? YES Wired? ❑YES ❑ NO; <br /> Locking device on cover? ES ❑ NO; Diameter of vent and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: f pits; _ diameter; ft liquid depth; <br /> ft to residence; ft ell ; ft to property line; <br /> ft to ordinary high water mark o e or stream; ft to edge of slopes <br /> greater than ; seepa inlet -elevation ft; bottom of <br /> seepage pit elevation ft. <br /> . <br /> (10) SEEPAGE BED SIZE: / "ft width; _3 7 ft length; m --�e)' tile depth; <br /> 00 Q lineal feet tile; S2 ft to residence; go ft to well ; ? /et ft to lot or <br /> property line; €\/4L ft to ordinary high water mark of lake or stream; A/4 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 el 7 ' ft. <br /> (11) SEEPAGE TRENCH: Total length of seepage trench • width ft; <br /> tile depth ft; o well ; ft to ordinary high water mark of <br /> lake or stream; ft to edge o s greater than 20% falling away toward lakes, <br /> water courses or drainage dit , elevation ischarge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH 115? RYES ❑ NO <br /> (13) Has system been installed in floodway? OYES WO Floodplain? OYES 200 <br /> DILHR-SBD-6095(N.05/80) 1 / .r.2a1-4-- ®Z I Se-, o f _ 0,14,41 <br /> ` Signature of Inspector: OJ <br />