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DEPARTMENT OP'INDUSPRY, 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 ❑ALTERNATIVE I State Plan I.D.Number <br /> (11 assigned) <br /> ❑Holding Tank El In-GroundPressure ❑Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER. j j�/2_ INSPECTION DATE: <br /> J <br /> BENC RK( ermanent reference point)DESCRIBE IF DIFFERENT FR�OM�PL�A�N REF.PT.ELEV.: CST REF.PT.ELEV. <br /> �e <br /> Nam.of Plu mtier-. IMPIMPRSW—N.. County: Sanitary Permit Number: <br /> LZO-cl &" o 3059 ZAZ4 4105 96 067 <br /> 3 <br /> SEPTIC TANK/ OLDING TANK: <br /> MANUF,RR LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER <br /> ,[ PROVIDED: PROVIDED <br /> •t ZYES ❑NO —]YES ❑NO <br /> BEDDING-. VENT CIA. VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH <br /> ` ALARM FEET <br /> E,a.FRUM LINE. f AIR INLET. <br /> ❑YES NO / L�l�/�` ❑YES ONO NEAREST "T `' `"-f �v� -✓ Z -J"' <br /> DOSING CHAMBER: <br /> MANUFACTURER ]BEDDING LIQUID CAPACITY JPUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABE i LOCKING COVER <br /> PROVIDED. PROVIDED: <br /> DYES ONO ❑YES ❑NO OYES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) OYES ❑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 /> WIDTH ! LENGTH NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA. =PITS LIQUID <br /> BED/VRE-WH `�/ ' /. �1 / TRENCHES MATERI L: PIT DEPTH. <br /> DIMENSIONS !1 a- T l �� <br /> GRAVEL DEPTH FILL DEPTH UISTH.PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF Pq OPERTV WELL. BUILDING: VENT TO FRESH <br /> BELOW P PES`,/ ABOVE COVER ELEV INLET ELEV.END {{ PIPES FEETFRLINE. AIR INLET: <br /> 4,2 3� b� NEAREST7----t. 11,16, r <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 /> meets the criteria for medium sand. TIONS MEASURED. <br /> ❑YES NO <br /> SOIL COVER. TEXTURE PERMANENT MARKERS. 7DYES <br /> BSERVATION WELLS <br /> DYES ❑NO NO <br /> DEPTH OVFH TRENCH BED DEPTH OVER TRENCH:BED DEPTH OF TOPSOIL SODDED SEEDED 171YES <br /> CHED <br /> CENTER EDGES <br /> ❑YES ❑NO ❑YES ❑NO ❑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 DIS. TR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.. ELEV. DIA. ELEV. PIPES CIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> EYES ❑NO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: 'NUMBER OF PROPER TV WELL: BUILDING. <br /> FEET FROM LINE: <br /> DYES ONO ❑YES El NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. 7l1A <br /> TITLE. <br /> DILHR SBD 6710 (R.01/82) -CA 'GG f' 4' <br />