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REPORT ON INSPECTION OF SANITARY PERMIT # <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection <br /> 1 <br /> Name, Address , License No. of Installing plumber Time of Inspection <br /> (3)INSTALLATION CONSISTS OF: ❑ Septic Tank [' Seepage Trench ['Dosing Chamber <br /> ['Seepage Pit ❑ Seepage Bed [' Holding Tank ❑ Fill System <br /> (4)BENCHMARK: (Permanent reference Point) Describe : <br /> Elevation of vertical reference point: Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: <br /> (6)SEPTIC TANK: Manufacturer: Liquid Capacity: <br /> Tank Inlet Elevation : Tank 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 cycle gallons ; total capactiy of distribution <br /> lines gallon ; size of pump head; gallon per minute • <br /> , <br /> horsepower ; brand name of pump and model number . <br /> Is the warning device installed? OYES LINO Wired? DYES ❑NO <br /> (8) HOLDING TANK: Manufacturer ; # of gallons • <br /> ; <br /> construction ; depth to the cover ft; If septic tank is <br /> being used are baffles removed? ❑ YES ❑ NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? 0 YES ❑NO; Wired? OYES ❑ NO; <br /> Locking device on cover? OYES 0 NO; Diameter of vent and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; <br /> ft to residence; ft to well ; ft to property line; <br /> ft to ordinary high water mark of lake or stream; ft to edge of slopes <br /> greater than ; seepage pit inlet pipe-elevation ft; bottom of <br /> seepage pit elevation ft. <br /> (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; <br /> lineal feet tile; ft to residence; ft to well ; ft to lot or <br /> property line; ft to ordinary high water mark of lake or stream; 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 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? OYES ❑ NO <br /> (13) Has system been installed in floodway? OYES ❑NO Floodplain? EYES ❑ NO <br /> DILHR-SBD-6095(N.05/80) — <br /> Signature of Inspector: <br />