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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR & HUMAN RELATIONS WI PRIVATE SEWAGE SYSTEMS DIVISION <br /> MADISON, <br /> P.O. BOX 7969I53707 BUREAU OF PLUMBING <br /> CONVENTIONAL ElALTERNATIVE [tte Plan l.D.Number: <br /> assig n ed) <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER: 1 ADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> i a.r S�i^ d ? - 7.3 <br /> BENCH MARK(Permanent reference poinitPOESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV <br /> 8� <br /> Name of PI ber: P/MPRSW No.. County: Sanitary Permit Number: <br /> —04/ Lao [ �✓r� P ���I S�% /� �f2 <br /> SEPTIC TANK/H64Bf#6'TANK: <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> 7 L� 7% PROVIDED: PROVIDED: <br /> V ,Z / XYES ONO DYES [:]NO <br /> BEDDING: VENT DIA.: VENT MATL.. HIGH WATER NUMBER OF ROAD: r PROPERTY WELL: JBUILG: VENT TO FRESH <br /> !/ ALARM FEET FROM �/ LINE:��r A DIN0LAIR INLET: <br /> ❑YES NO C� OYES ONO NEAREST a �Q <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES ONO ❑YES ONO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING:JVENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LEN(]TH DIAMETER 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- NO.OF DISTR PIPE SPACING COVER ["I"' <br /> DIA. #PITS. LIQUID <br /> BED/773"EI�CfI a ` TRENCHES / M T RIAL PIT DEPTH: <br /> DIMENSIONS /�J JS / /P <br /> GRAVEL DEPTH FILL DEPTH JDISTR.PIPE DISTR.PIPE IDISTR.PIPE MATERIAL NO.D NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> BELOW PIP A ABOVE COV R: ELEV.INLET ELEV.END PIPES: LINE, AIR INLE <br /> /IE �/ i/� FEET FROM 1-?/ 7`7 <br /> (O Y NEARESTs c3�/ <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 ITEXTURE PERMANENT MARKERS OBSERVATION WELLS. <br /> DYES ONO I OYES ONO <br /> 177 <br /> RENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED SEEDED- MULCHED EDGES: <br /> OYES ONO OYES ENO 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 /> ELEVATION AND <br /> ELEV.. ELEV.. DIA.. ELEV.. PIPES. DIA.: <br /> DISTRIBU110N <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS: <br /> ❑YES ONO OYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. <br /> FEET FROM LINE: <br /> ❑YES ❑NO ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIG T RE: TITLE: <br /> DILHR SBD 6710 (R.01/82) <br />