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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 <br /> MADISON,WI 53707 BUREAU OF PLUMBING <br /> CONVENTIONAL EIALTERNATIVE State Plan I.D.Number: <br /> ❑Holding Tank ❑In-Ground Pressure ❑Mound (if assigned) <br /> 0NON OF PERMIT OLDER: ADDRESS OF PERMIT HOLDER: SSSWS INSPECTION DATE: <br /> B CH MARK(Permanent reference point,DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV. <br /> Name 1 Plumber: / MP/MPRSW No.: County Sanitary Permit Number: of , <br /> I 03os9 <br /> SEPTIC TANK/H0rDTRG-rA*K <br /> LBD�DINGC <br /> FATURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKINGCOVER <br /> PROVIDED: PROVIDED <br /> (f (cam• -C C7'� YES ONO ❑YES ONO <br /> . VENT DIA.. VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH <br /> ALARM. FEET FROM LINEE ' ��/ I� AIR INLET. <br /> YES NO ❑YES ❑NO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL JILOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES ONO ❑YES ❑NO I DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATION A L: NUMBER OF PROPERTY WELL TILDING VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) 1 1:1 YES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH 11AMETER 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 /> CONVENTIONAL SYSTEM: <br /> BED/ WIDTH:, LENGTH/ / NO OF DISTR­PIPE COVER INSIDE DIA SPfTS LIDO ID <br /> DIMENSIONS / 3 / TRENCHES / MAT RIAL: PIT DEPTH. <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTq PIPE DISTR.PIPE MgTERIAL NO D R NUMBER OF PROPERTY WELL BUILDING: V NT TO FRESH <br /> BELOW PIP / ABOVE CO�ER ELEV,INLET ELEV.END �a /� PIP FEET FROM LINE// /�y/s�I 171 <br /> y/ �/r <br /> V _. YJ L r O / AIR IN <br /> � + 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 /> ❑YES NO <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> ❑ <br /> OIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS <br /> OYES ONO 1:1 YES FIND <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED. <br /> CENTER EDGES. <br /> DYES FIND ❑YES ONO OYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH NO.OF LATERALSPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE IMANIFOLD MATERIAL NO.DISTR <br /> ELEVATION AND . DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> 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 1-1 NO OYES ONO <br /> COMMENTS: PERMANENTMARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> OYES 1:1 NO OYES ONO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE: �r4 TITLE: <br /> DILHR SBD 6710 (R.01/82) ((-! <br />