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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 /> MADISON,WI 53707 <br /> ❑CONVENTIONAL El ALTERNATIVE r,e <br /> Plan I.D.Number: <br /> ❑Holding Tank ❑ In Ground Pressure ❑Mound assigned) <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION D TE: <br /> rya � P <br /> BENCH MARK(Permanent refere ce point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.IT.ELEV.: <br /> )4611 <br /> Name of Plumber: IM <br /> PIMPRBW.No.: County: Sanitary Permit Number: <br /> 21 <br /> �,7 �� 5 Z�3 11371 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: IWARNINGLABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES ONO ❑YES [:]NO <br /> BEDDING: VENT DIA.. VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH <br /> ALARM FEET FROM LINE: AIR INLET <br /> DYES ❑NO ❑YES ❑NO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL L <br /> KING COVER <br /> PROVIDED: VIDED: <br /> ❑YES ONO ❑YES ❑NOYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING. VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: <br /> PUMP ON AND OFF) DYES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moistureat the depth of plowing 1,1 1111AMITER MATERIAL AND MARKING <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 TRENCHES <br /> RENC DISTR.PIPE SPACING: COVER INSIUE DIA.. #PITS: LIQUID <br /> BED/TRENCH Z�AV2 • TR ENC1 ES / MATERIAL: � PIT DEPTH <br /> DIMENSIONS f <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE IDISTR,PIPE IDISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH <br /> BELOW PIPES ) ABOVE COVER- ELLEEVV.IINLLET ELEV.END: / PI -. LINE: AIR INLET:/ <br /> FEET <br /> NEARESTO--s / 3 <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 /> SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. <br /> DYES ONO OYES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. SEEDED. MULCHED. <br /> CENTER EDGES. <br /> ❑YES ONO ❑YES ONO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH. LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.. ELEV: DIA.. ELEV.: PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS. <br /> ❑YES ❑NO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> DYES El NO OYES ONO NEAREST <br /> 0}\) <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGN RE: ^ TITLE: ,L <br /> DILHR SBD 6710 (R.01/82) <br />