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REPORT ON INSPECTION OF SANITARY PERMIT # lfll <br /> .. <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection <br /> ame, Address, License No. of 'Installing plumber Time of Inspection <br /> /D . <br /> (3)INSTALLATION CONSISTS OF: ❑ Septic Tank [:] Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit Q Seepage Bed ❑ Holding Tank [] Fill System <br /> ermanen referencePoint) Describe: <br /> Elevation of vertical reference point: Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: �r .C_�, < ! , el, <br /> (6)SEPTIC TANK: Manufacturer: ;7'-1--1 Liquid Capacity: <br /> Tank Inlet Elevation: " Tank Outlet Elev: <br /> # ft to lot or property line: L� _57 `' # ft to well :4'>� <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 /> horsepower ; brand name of pump and model number <br /> Is the warning device installed? ❑YES [-]NO Wired? ❑YES ❑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? YES [] NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? ❑ YES []NO; Wired? []YES ❑ NO; <br /> Locking device on cover? []YES ❑ 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: 'r` ft width; % ft length; y~" the depth.; <br /> 1 l i.neal feet tile; i> ft to residence;,; i(v_ ft to wel l 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? ®YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES ❑NO Floodplain? [-]YES ® NO <br /> DILHR-SBD-609 N. 8 <br /> Signature of Inspector: <br />