Laserfiche WebLink
REPORT ON INSPECTION OF SANITARY PERMIT # //3 ('(/`!) <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection <br /> Name, Addr ss, License No., of installing plumber Time of Inspection <br /> s <br /> (3)INSTALL TION CONSISTS OF: 'Stbaeptic Tank ❑ Seepage Trench [posing Chamber <br /> ['Seepage Pit Seepage Bed ❑ Holding Tank ❑ Fill System <br /> (4)BENCHMARK: (Permanent reference Point) Describe : <br /> T .- = e <br /> -r <br /> /(-"(--Elevation of vertical reference point: Slope at site: / Ce <br /> (5)MATERIAL AND DEPTH OF SEWER: ' ' ,Pv4-- el= c,- y`>� 0 ,,4. <br /> (6)SEPTIC TANK: Manufacturer: 6.1 4:-/-' Liquid Capacity: J_Zf2 <br /> Tank Inlet Elevation: .7, Tank Outlet : g, y <br /> # ft to lot or property line: 2 ;" # ft to well : i+ - <br /> (7)DOSING TANK: Manufacturer: # of gallons : <br /> # of gallon pump set for a cycle gallo ; total capactiy of distribution <br /> lines gallon ; size of pum head; gallon per minute ; <br /> horsepower ; brand name of m nd model number <br /> Is the warning device installed? S ❑NO Wi d? DYES ❑NO <br /> (8) HOLDING TANK: Manufacturer ; # of gallons ; <br /> construction , depth to the cover ft; If septic tank is <br /> being used are baffles removed? ❑ Y ❑ NO; ft from residence; <br /> ft from well ; ft from prope li . Type of warning device <br /> Is the warning device installed? ❑ YES • Wired? OYES [] NO; <br /> Locking device on cover? OYES ❑ Diameter of vent and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: # pits; ft diameter; ft liquid depth; <br /> ft to residence; ft to 1 ; property line; <br /> ft to ordinary high water mark of stream; ft to edge of slopes <br /> greater than ; seepage pi inlet pipe-e ion ft; bottom of <br /> seepage pit elevation ft. <br /> (10) SEEPAGE BED SIZE: 1 ? ft width; __3e ft length; /fj' tile depth; <br /> /,/ lineal feet tile; 2.6 ft to residence; -- ft to well ; 75,- ft to lot or <br /> property line; 7 C; 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 leng of seepage trench ft; width ft; <br /> tile depth ft; to well ; ordinary high water mark of <br /> lake or stream; ft to edge o greater than 20% falling away toward lakes , <br /> water courses or drainage ditches• evation nk discharge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH 115? JES ❑ NO <br /> (13) Has system been installed in floodway? OYES zIO Floodplain? OYES ENO <br /> DILHR-SBD-6095(N.05/80) �"' <br /> Signature of Inspector: � ._,,Afie-df--c--� ?J ` 7P6L ) <br />