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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 /> MA4ISON,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE State Pian l o.Nua <br /> nl a..iPnedl <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> N E Ot PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE'. _ <br /> A10 Ob W 5-11763 <br /> BENCH MARK IPer -in,reluence Pantl DESCRIBE IF DIFFERENT FROM PLAN REE PT.ELEV.'. CST REF PL ELEV <br /> Name of Plumber MP/MPRSW No.. County Sanitary Permu Number. <br /> /' 03U5`l 66/6 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER nCAPACII TgNK INLET ELE V.. TANK OUTLET EL§V. p OVIDEDIABELPROVIDEDT/ l C ,.7 0 JA -��+ YES ❑NO ❑YES ❑NO <br /> BEDDING. VENT DIA.. VENT MATL. HIGH WUMBER OF ROAD PROPERTY WELL. / BUILDING'. VENTTOFRESH <br /> /1ALARMET FROMr LIN Z 6( / AIR INLET <br /> ❑VES NO �( ❑YEAREST /WI1 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIOVID CAPgC ITY PUMP MODEL PUMP/SIPHON MANUFACTURERWARNING LABEL LOCKING COVER <br /> PROVIDED'. PROVIDED. <br /> ❑VES ❑NO ❑YES [:]NO []NOGALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL 6UILDINc VENTTOFRESH <br /> NIR INLET. <br /> (DIFFERENCE BETWEEN FEET FROM LINE <br /> PUMP ON AND OFF) ❑YES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moisture at the depth ofplowing LENrTH DIAMETER MATERIAL AND MARXINc, <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 /> WIDTH LENGTH NO.OF DISTR PIPE SPACING. COVER INSIDE Ulq ItPITS LIQUID <br /> BED/'TAGNBFI / TRENCHES // / MATE AL'. PIT DEPTH. <br /> DIMENSIONS yj .2. � <br /> GRAVELDEPTH FILL DEPTH DISTR PIPF DISTR PIPE DISTR PIPE MATERIAL NO DISTR NUMBER OF PROPERTY WELL BUILOINy VENT TOFRESH <br /> BELOWPIPEy r/ gaavE c�vER ELEv INL�T ELf`�r�y ,a �� PIP FEET FROM Llrv �..-. AI Ff. <br /> �O 3� 'f `f 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 /> ❑YES NO <br /> SOIL COVER TEXTURE PERM ANENT MARKERSORSEHVATION WELLS <br /> I!]YES 1:1 NO ❑YES ONO <br /> DEPTH OVER TRENCH:BED DEPTH OVER TRENCH:BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES <br /> 1:1 YES ❑NO ❑VES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH. NO.OF LATERAL SPACING. GRAVE L DEPTH BE LOW PIPE FILL DEPTH ABOVE COVER <br /> BED/TRENCH TBENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR. DISTR.PIPE DISTRIBVTI ONPIPE MATERI AL&MARKING. <br /> ELEV. ELEV. DIA ELEV.' PIPES DIA.' <br /> ELEVATION AN <br /> DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VEITICALLIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> EYES <br /> ❑NO : YES ENO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS: NUMBER DP L?IOE ERTV WELL. BUILDING'. <br /> FEET FROM <br /> ❑YES ❑NO ❑YES <br /> ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIG�Rfj E. <br /> DI LHR SBD 6710 (R.01/82) / n ��� - <br />