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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 S"I,.)Pill 1.0Number. <br /> ❑Holding Tank In-Ground Pressure ❑Mound (11 ass <br /> NAME F PERMIT HOLM IT ADDRESS OF PERMIT HOLDER. INSPECTION DATE. <br /> eGLLCi .ed J .SS ,2 �;,_ 4 _ 7- <br /> RENCH MARK IPermaner,relerence pornrl pESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.. [STRIP PT,ELEV <br /> Narrinyl Plu MP/MPRSW No C—PI, S—Cir,Perron Number <br /> �' <br /> SEPTIC TANK/H LDING TANK: <br /> MANUFACTURERLIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LAB EL LOCKING COVER <br /> G �( / /, / y PROVIDED'. PROVIDED. <br /> 7 J U 5 d r 3J �p VES ❑NO ❑VES ❑NO <br /> BEDDING. VENT DIA.'. VENT Mg IHIGH WATER NUMBER OF ROAD. PROPERTY W{� BUILDING. VENT TO FflESM <br /> ` / I ALARM FEET FROM 7 /.,{_ LINE -7 / "✓ IAIR INLET'. <br /> ­ <br /> EYES NO 4 ❑YES [:]No NEAREST vs- Cts' <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. IIOVID CAPACIIV PUMP MODEI. PUMP,r$IPHON MgNV FACiIIREH WggNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED- <br /> ❑YES ❑NO EYES ❑NO ❑VES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHQPERTv WELL Bu1LDINc VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) ❑VES ENO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MAHKIN6 <br /> or excavation, (If soil can be rolled into a wire,construction shall cease until <br /> the soil is dry enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> BED/T^SWMWIDTH LENGTHI, NG.OF D1sTq.PIPE SPACING COVER NS1DE DIA #PITS LwUID <br /> DIMENSIONS <br /> ONS �l 1 / l TRENCHES MATER�P.L'.��� PIT DEPTH <br /> //�✓✓�w�, <br /> GRAVELDEPTH FILL DEPTHUISiH PIPF pISTR.PIPE DISTR.PIPE MgTERIAC NO pISTR NUMBER OF PROPERTY WELL BUILDING'. V NT TO FRESH <br /> BELOW P7Sp ABOVE CDyER ELEv/IFr ELEv.ENO_ �r ^ P1PEyt FEET FROM LINE ��u .f �7/ A17R INLEj. <br /> NEAREST —3d� <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 /> ❑VES ONO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TEXTURE PERM A NEXT MARKERS OBSERVATION WELLS <br /> DEPTH OVER rRFNC11'BEU DEPTH OVER TRENCH BED EYES ONO ❑YES ❑NO <br /> UEPiH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENiEH EDGES <br /> DYES ENO DYES ❑NO EYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH NoOOCMES. LATERAL SPACING. GgAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. <br /> DIMENSIONS <br /> MgNIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAD NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL a MARKING. <br /> ELEVATION AND ELEV. ELEV. DIA ELEV. PIPES DIA.'. <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING GRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> EYES [:]NO EYES ENO <br /> COMMENTS: PERMgrvervT MARKERS OBSERVATION WELLS: NUMBER OF PROPER WELL Bua01No-. <br /> FEET FROM LINE' <br /> DY ES ❑NO EYES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SI T RE. TITLE'. <br /> 4J <br /> DILHR SBD 6710 (R.01/82) ' <br />