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REPORT ON INSPECTION OF SANITARY PERMIT # 1 ,71Y / '?O rv) <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Ins ection <br /> I ilY <br /> Na res 'iicenseo. of installing Plumber Tim of Inspection <br /> s <br /> (3)INSTALLATION CO IISfre EKe tic Tank [' Seepage Trench ['Dosing Chamber <br /> ❑Seepage Pit EKepage Bed ❑ Holding Tank ❑ Fill System <br /> (4)BENCHMARK: (Permanent reference Point) Describe: <br /> Elevation of vertical reference point: / o e Slope at site: a <br /> (5)MATERIAL AND DEPTH OF SEWER: 4' " PG/C.- > ' " Ca,cj � <br /> (6)SEPTIC TANK: Manufacturer: Liquid Capacity: �' . <br /> Tank Inlet Elevation: 4 7 ' T 1 <br /> 7 Tank Outlet Elev: q 3- s1 <br /> # ft to lot or property line: `j�0 I # ft to well : 29 <br /> (7)DOSING TANK: Manufacturer: # of gallons : <br /> # of gallon for a cycle gallons• distribution <br /> lines gallon; size head; gallon per minute ; <br /> horsepower ;• b name of pump a el number • <br /> Is the warning device installed? OYES ❑NO Wired? - ❑NO <br /> (8) HOLDING TANK: anufacturer ; # of gallons , <br /> construction ; depth to the cover ft; If septic tank is <br /> being used are baff ved? YES ❑ NO; <br /> ft from well ; from proper • . Type of warning device <br /> Is the warning device installed? ❑NO; Wired? OYES ❑NO; <br /> Locking device on cover? YES ❑ NO; • r of vent and material ; <br /> Distance from b ' ing to vent <br /> (9) SEEPAGE-RIZ SIZE- # of pits; ft diame t i uid depth; <br /> ft to residence; to property line; <br /> ft to ordin • water mark of lake or sir ; ft--to--edge of slopes <br /> greater tha ; seepage pit inlet pipe-elevation ft; bottom of <br /> seepage pit elevation ft. <br /> (10) SEEPA9E BED SIZE: c2o ft width; ,.Af ft length; i '.f;4i19, depth; 1 <br /> b S lineal feet tile; 3. , ft to residence;.$ 2 ft to wel 1 ; —4-0, ft to lot or <br /> property line; /- ft to ordinary high water mark of lake or stream; Me 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 ..aipt qii. ft. <br /> (11) SEEPAGE TRENCH: Total length of seepage trench ft; width ft; <br /> tile depth ft; ft to well ; ft to ordinary high water mark of <br /> lake or stream; ft to edge of slopes greater than 20% falling away toward lakes , <br /> water courses or drainage ditches; elevation of tank discharge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH 115? ''YES ❑ NO <br /> (13) Has system been installed in floodway? OYES ONO Floodplain? OYES a-NO <br /> DILHR-SBD-6095(N.05/80) <br /> Signature of Inspector: p/ / 6t,�1,,,eP <br />