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11 - <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> BUREAU OF PLUMBING <br /> P.O.BOX 7969 <br /> MADISON,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE I scare PLAID.N„meer <br /> IH,>•r,P„�i <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> N E OF PERMIT�DER. AOGRESS OF PERMIT HOLDER'. ,y `�pvyA INSPECTION DATE. <br /> Qa' �7a /Jte � G�iJ O ♦V 1 <br /> BENCH RK(Perma em reference P-0 D ISE IF DIFF€RENT FROM PL77N. REF.PL ELEV.'. CST REr.PT.ELEV.' <br /> Name Plumber / MPR$//�. Counry Sanitary Pcrmu Numeer <br /> XS PTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAPACITY TANK INLET ELEV TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> PROVIDED. PHOVI DED' <br /> ,Ln, YVEy�S��❑NO EYES LINO <br /> BEDDING VENT DIA. VENT MALL. HIGH WATER NUMBER OF ROAD. PROPERTY BUILDING VENT 'E <br /> FRESH <br /> U ALARM FEET FROM uNE <br /> AIR INLET <br /> -]YES NO �^ ❑YES [:]No NEAREST ✓ l D d '�" <br /> DOSING CHAMBER: WARNING <br /> MANUFACTURER BEDDING LIQUID CAPACIIv PUMPMODEL PUMP!SIPHON MANUGACTIIREH pROVID D`ABEL PROVIDED OVER <br /> DYES ❑NO DYES 11 NO [-]YES END <br /> PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VAEHN NLOT RESN <br /> GALLONS PER CYCLE LINE <br /> (DIFFERENCE BETWEEN FEET FROM <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING <br /> FORCE <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until <br /> MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH TR EONFME$ DISTR IP SPACING COVER INSIDE DIA #PITS LIQUID <br /> BED/TRENCH r / f f MATE IAL. j PIT DEPTH'. <br /> DIMENSIONS (q ( f7 L'" <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPF IS TR PIPE DISTR.PIPE MATERIAL NO.DISTR. flft/MBf fj DF PROPERTY / C. BUILDING. VENT TO FRESH <br /> BELOW PIPE ABOVE covEp ELEV INLET I.ELEV END PIPES FEET FROM <br /> L. <br /> _ f AI INLET <br /> / Lj <br /> ,f <br /> 7S Y G. �J NEAREST <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 ENO <br /> PERMANENT MARIE IS OBSERVATION WELL$ <br /> SOIL COVER rezruRE <br /> DYES [:]NO DYES END <br /> DEPTH OVER TRENCH BD DEPTH OVER TRENCH;BD DEPTH OF TOPSOIL sOUDD SEEDED MULCHD <br /> CENTER EDGES <br /> FIVES ❑NO ❑YES ❑NO ❑YES END <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH NO.OF LATERALSPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES. <br /> DIMENSIONS <br /> ELEVD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE OISTNIBUTION PIPE MATERIAL&MARKING <br /> E <br /> ELEV.'. ELEV. DIA. ELEV.' PIPES OIAc <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MAT PHIAL VERTICAL LIFT CORR ESPON DS TO APPROVED <br /> INFORMATION PLANS <br /> EYES ❑NO ❑VES ❑NO <br /> CDMMENTSI PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF LINE <br /> PROPERTY WELL. BUILDING. <br /> EYES ❑NO EYES ❑ FEET FROM NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. TITLE <br /> SIG.gA,UR E. I� <br /> DILHR SBD 6710 (R.01/82) ✓/�J`J' <br />