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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY 8 BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.Box 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON.WI 53707 State Plan LD.Number4 . <br /> CONVENTIONAL ❑ ALTERATIVE (If assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> ry ME OF PEHM1IIi HO ER ADDRESS OF PERMIT HOLDER — '1 c INSPECTION DATE <br /> yD �fx/ l�u.� ry'? <br /> B NCH MA^,(Permanent ref rence point)DESCRIBE IF DIFFERENT FROM PLAN. REF_PC ELEV_ CST REE PT ELEV_- <br /> Name 1Pi.;mbe--- — MPIMPRSWNoc County. San nary Per m It Num be <br /> I <br /> SEPTIC ANK/HOLDING TANK: <br /> M ANUnACTURER: ` / LIOUIDCAPACITV: TANK INLET ELEV.: TANK OUTLET ELEV.' WARNING LABEL LOCKING COVER <br /> I' PR VIDED: PROVIDED <br /> A L��c 17 Q. YES ❑NO NO <br /> BEDDING. VENT DIA.' VENT MATLHIGH WATER NUMBER F ROAD I PROPERTY WELL BUILDING. VENT TO FRESH <br /> ry ALARM'. LINE'. AIR INLET'. <br /> EYES ❑NO CICS 1 H� NEARES7�I � IUL' ,IL' <br /> DOSING CHAMBER: _ <br /> MANUFACTURER. BEDDING. LI QUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER' WARN INGLABEL LOCKING COVER <br /> PROVIDED: PROVIDED' <br /> ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INTEL <br /> PUMP ON AND OFF ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH'. DIAMETER' MATERIAL AND MARKING. <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> VENTIONAL SYSTEM: <br /> IF WIDTH: LENGTH: NO OF I DISTR.PIPE SPACING: G INSIDE DIA.'. #PITS: LIQUID <br /> BED RENCH <br /> ONS i TRENCHER: / MAT RIAL PIT ,� <br /> DEPTH'. <br /> NSIONS 14 1 ✓ (� <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DI5TR.PIPE DISTR.PIPE MATERIAL NO.DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH <br /> BELOW PE5 A PVE GOVII ELEV.INLET EL EN - ,,( �q PIP LINBL,, 7 'n a/ AIR INL T' j <br /> 1 y+ /j S / ,��d j NEAREST�il <br /> r <br /> MOUND SY TEM: be <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVER j TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS: <br /> ❑YES [—I NO Ll YES ❑NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCHBED DEPTHS OF TOPSOIL SODDED-. SEEDED: MULCHED'. <br /> CENTER: EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: NOOF HES: LATERALSPACING' GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVERTRENC ' <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL B MARKING'. <br /> ELEV.: ELEVr. DIA.'. ELEV.. PIPES. DIA.' <br /> ELEVATION AND <br /> DISTRIBUTION HOLESIZE. HOLE SPACING: DRILLED CORRECTLY rCOVER MATERIAL' VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> [__1 YES ❑NO EYES ❑NO <br /> PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING: <br /> COMMENTS: FEET FROM LINE <br /> ❑YES ❑N Ll YES ❑NO NEAREST—� <br /> err y„izf — , PI ��¢ s yStJ� <br /> Retain in county file for audit. <br /> Sketch System an <br /> Reverse Side. SIGNATURE - - TITL <br /> SBD-6710(R.06/88) <br />