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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> LABOR & HUMAN REI-5A'FION9 PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O. BOX 7969 <br /> MADISON,WI 53707 BUREAU OF PLUMBING <br /> 9CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound (If assigned) <br /> NAM OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> G V_ 12� /,-X-3 <br /> BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.'. <br /> Name of Plu ben MP/MPRSW No. County Sanitary Permit Number: <br /> 0L?3IJ <br /> SEPTIC TANK/HOLD NG TANK: <br /> MANUFACTURER, Lam. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLY ELEV.: WARNING LABEL LOCKING COVER <br /> �j _ << PROVIDED: PROVIDED: <br /> Q T-� YES ❑NO ❑YES ONO <br /> BEDDING: VENT DIA.: VENT MATL. - HIGH WATER NUMBER OF ROAD: PROPERTY WELL: 113 DINCyI VENT TO FRESH <br /> �[ y ALARM FEET FROM LINE: � f AIR INLET: <br /> ❑YES NO �/ G-Z�' ❑YES ❑NO NEAREST ` ✓�� �� <br /> DOSING CHAMBER: <br /> MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL JLOCKING COVER <br /> PROVIDED: PROVIDED: <br /> ❑YES ENO DYES ❑NO ❑YES ❑NO <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) ❑YES ❑NO 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 /> BED/TIR'ENCN'c- WIDTH. / LENGTH: NO.OF JDISTR.PIPE SPACING. COVER INSIDE DIA #PITS. LIQUID <br /> THE CHES. MAT`ER�. ' PIT DEPTH: <br /> DIMENSIONS �"'� r <br /> GRAVEL DEPTH FILL DEPTH JDISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY W L BUILDING: VENT TO FRESH <br /> BELOW L DEPTH <br /> ABOVE C VjFi-. DISTR,N%LyET.ELEV.END: PIP LINE AIR INLET: <br /> 4 ?If 147 NEARFEET P- �.i /� / y/ <br /> MOUND SYSTEM: 7 i�f�/ (r/Li <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <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 TEXTURE: PERMANENT MARKERS OBSERVATION WELLS. <br /> J <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED: <br /> CENTER EDGES. <br /> ❑YES ❑NO ❑YES ❑NO ❑YES El 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 /> DISTR IBUI ION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY VERTICAL LIFT CORRESPONDS TO APPROVED <br /> ❑ ❑ 7ATERIAL <br /> YES NO PLANS DYES El NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> El YES ❑NO ❑YES ONO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> JSWTRE: TITLE. <br /> DILHR SBD 6710 (R.01/82) <br />