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DEPARTMENT OF INDUSTRY, is <br /> 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 State Plan I.D.Number: <br /> (If assigned) <br /> ElHolding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT H LDER ADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> 'BENCH M (Permanent reference point;DES2CYFFERENT FROM PLAN: REF.PT. EV.: CST REF.PT.ELEV.: <br /> 1" t 2 d-4 e <br /> Name of Plumber. MP <br /> No County Sanitary Permit Number: <br /> �w 03os9 ?67917 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELEV: WARNING LABEL PROVIDED: LOCKING COVER <br /> IF? RYES ONO DYES ONO <br /> BEDDING: VENT DIA.. VENT MATL Fu' WATER NUMBER F ROAD. P.ROPERTV WELL: BUILDING: VENTTO <br /> FEET FROM \ LINE: I r J JI AI ET <br /> ❑YES NO l v� ❑YES ❑NO NEAREST /'l�o <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES LINO I ❑YES ONO I OYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM "E AIR WLET. <br /> PUMP ON AND OFF) I ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing v+srl, [1111METER MATERIAL AND MARKING <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> VIIDTH LENGTH NO.OF DISTH.PIPE SPACING COVER INSIDE DIA. -PITS LIQUID <br /> BED/TRENCH /) 2 / TRENCHES // / L MAT PIT DEPTH. <br /> DIMENSIONS !/Y T V <br /> FILL DEPTH DISTH.PIPF DISTR.PIPE DISTR.PIPE. MATERIAL. NO.DISTR. NUMBER OF PROPERTY WELL. BUILDING VENT TO FRESH <br /> HE I ul�Pu'I ABOVE COVER El EV I LF C ELEV.END s PIPETS LINE. r .L I AIR�IjN LET: <br /> u f g l Fit/� 3 IC NEARESFEET T '�V e <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 /> DYES ❑NO <br /> SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS <br /> J <br /> El YES ❑NO OYES ❑NO <br /> DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES , <br /> ❑YES ❑NO ❑YES ❑NO 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 INO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> EIEV.. ELEV. DIA. ELEV. PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> riULE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> ❑YES ❑NO I <br /> El YES El NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF �POPERTYR WELL: BUILDING: <br /> FEET FROM <br /> NE <br /> ❑YES ❑NO ❑YES ❑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) �' r <br />