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L! - <br /> 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 /> SZCONVENTIONAL ❑ALTERNATIVE State PlanLD.Numbec <br /> IU assigned) <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> 0 �&&A <br /> BENCH MARK( rmanent r erence point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV.. <br /> Name of Plumber: MP/MPRSW No.. County Sanitary Permit Number- <br /> SEP IC TANK/HOLDING TANK: <br /> MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> t �� PROVIDED IPROVIDED <br /> J2 / _ KYES LINO ❑YES ❑NO <br /> BEDDING: VENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD: PR OPERTV WELL: BUILDING VENT TO FRESH <br /> ALARM FEET FROM / 7 LINE. ! t LAIR INLET. <br /> DYES NO [—]YES ❑NO NEAREST ` /�~ �� <br /> DOSING CHAMBER: <br /> MANUFACTURER 7ING. LIQUID CAPACITv PUMP MODEL JPUMP/SIPHON MANUFACTURER JWARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED: <br /> S ❑NO DYES ❑NO I ❑YES 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) OYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at 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 /> the soil is dry enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> AM!!/TRENCH WIDTH LENGTH j NO.OF DISTR PIPE SPACING COVER JINIIDI DIA -PITS LIQUID <br /> DIMENSIONS �j rREN HEs � MAr RC! PIT <br /> —/ DEPTH: <br /> F7�ylH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OFPROPERTY WELL B ILDING. VENT TO FRESH <br /> y ABOVE COVER ELEV.INLLET ELEV.EN/D l PIPE FEET LINE. /' JAIR TO F <br /> �d xn I IV/ i 1 �l� NEARESTO—i � IUl <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 /> ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS <br /> ❑YES ❑NO DYES ❑NO <br /> DEPTH OVER TRENCRBED DEPTH OVER TRENCHrBED DEPTH OF TOPSOIL SODDED SEEDED M ULCHED <br /> CENTER EDGES <br /> ❑YES ❑NO OYES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH TNO OF RENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR IDISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELEVATION AND ELEV.. ELEV. DIA.. ELEV.. PIPES DIA.: <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> ❑YES ❑NO DYES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: INUMBER OF PROPERTY WELL. BUILDING. <br /> FEET FROM LINE <br /> ❑YES ❑NO ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGN TITLE. <br /> DILHR SBD 6710 (R.01/82) <br />