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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAF <br /> LABOR & HUMAN RELATIONS " PRIVATE SEWAGE SYSTEMS <br /> P.O.BOX 7969 BUR, <br /> MADISON,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE State Plan LD.Nube <br /> ❑Holding Tank ElIn-Ground Pressure ❑Mound (lf assigned) m <br /> NA E OF PE RMIT�.�H2O�LDER: // JADDRESS OF PERMIT HOLDER* INSPECTION DATE: <br /> NCH MARK(Permanert reference mt)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.. <br /> P <br /> Name of Plumber MPIMPR SW No.. County Sanitary Pern Number: <br /> o o S ' yo 6 � 7 <br /> SEPTIC TANK/ <br /> MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> /V /y YES ❑NO OYES ONO <br /> BEDDING. VE T DIA.. VENT MATL. HIGH WATER NUMBER O ROAD: PROPERTY JW� BUILDING. VENTTOFRESH <br /> "iALARMFEET FROM /, ` / LAIR INLET: <br /> DYES KIND ❑YES ONO INEAREST GL t 'l 17" <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED: <br /> ❑YES ❑NO ❑YES ONO I ❑YES 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 ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH 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 JINSIDE DIA -PITS LIQUID <br /> BED/TFI P / TRENES MAT PIT DEPTH <br /> DIMENSIONS <br /> GRAVEL DEPTH FILL DEPTH JDISTR.PI F DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY BUILDING VENT TO FRESH <br /> BELOW PIPESif ABOVE CO ELEV.INLET ELEV.END �'+�TFEET V PIPES LINE; AIR INLET <br /> ' t M F <br /> NEARESTO-► <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 meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER ITEXTURE MANENT MARKERS OBSERVATION WELLS <br /> PER <br /> EYES ❑NO 1DYES ❑NO <br /> DEPTH OVER TRENCH'BED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES. <br /> OYES ❑NO 1 ❑YES ONO ❑YES ❑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. IND.DISTR. DISTR.PIPE <br /> ELEVATION AND 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 ❑NO ❑YES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> ❑YES ❑NO ❑YES El NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE. ]TITLE. <br /> DILHR SBD 6710 (R.01/82) / <br />