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5A- ,557 l co <br /> DEPARTMENT OF INDUSTRY, 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 F-1 ALTERNATIVE sar.Plan1.D.NI,rnoer <br /> m a.aen�1 <br /> Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTIUN DATE. <br /> e <br /> BENCH MARK HE,rmanentrefer—ce porn,(DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.' CS1 HE4.PT.ELEV <br /> /) 4" & w / <br /> V— I M 'MPR$W Nn C San�lery Permit I,er <br /> SE Z /HOLDING ANK: <br /> SAND F HER LIQUID CAPACITY TANK INLET ELEV TANK OUTLET ELEV. WARNING LABEL LOCKING COVER <br /> ry ( PROVIDED. PROVIDED <br /> (�' . <br /> c6L"/1(j / 7t 5_ p - LXYES LINO ❑VES ONO <br /> Re DDINc <br /> VENT CIA. VENT MALI HIGH WATER NDMBEROF ROAD PROPERTv WELL. BUILDING VENT TO FRESH <br /> )� ALARM LINE `f - AIRINLET <br /> FEET IFDYES NO /I CYi' X YES ❑NO NEARES OM F I I Al 27 / <br /> DOSING CHAMBER: sem' I <br /> MANV FACT UHfN f1EDUING L 11111111 f:nPAL I I Y 'IIMP MIIDII IP PUMP.SIPH, AANUI ACI FIT WARNING LABEL LOCKING COVER <br /> PROVIDEDPROVIDED <br /> ❑VES ONO ❑VES ONO ❑VES ONO <br /> GALLONS PER CYCLE' PUMP 11NTHOLs OPERATIONAL NUMBER OF ER1111 HTY wEu BUILDmc vervr TO FRESH <br /> (DIFFERENCE BETWEEN _ FEET FROM LINE AIRINLET <br /> TTOF <br /> PUMP ON AND OFF) ❑YES ONO NEAREST—► <br /> SOIL ABSORPTION SYSTEM.Check theso'J moistureat the depth of plowing —11Nr•FIT <br /> ITA",PIH MATT FIAT AND MAHKwI, <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 LE NG nI NO nr UISIH PIP1 svnallo I:OVFH INSIut Uln xPl rs uaulD <br /> BED/TRENCH NO,honS nmlEUlnu PfT DEPnI <br /> DIMENSIONS <br /> C.HAVPL DEPTH FILL DEPT N u1SIH PIP( 1115TH PIPL OISTR PIPE MATERIAL NO nlSTll NUMBER OF A OPERTY WELL ew LOING vENr TO FRESH <br /> utLnW P1PEs ABOVLCOVEH IILV IN'II ELLV INO PIrIS FEET FROM uNE AI.INLET <br /> NEAREST <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 /> OYES ❑NO <br /> SOIL COVER IE%TVHE PI OMANI N 1 111111 HS uuSLlrvAnnN WELLS <br /> 11YES E]NO DYES ONO <br /> ULPIII I]VEH IH4N(:II NFD DFPTII OVFR iHLNCII H4O III V11111I IOPtiL11L ti[IUII(II SEI UE IT MVLCHFD <br /> CENTER EDGES <br /> ❑YES. ONO ❑YES ❑NO ❑YES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LLrvGn1 N0OF LATERAL SPAarvr OHAVLL DEPTH BI LOW PIP[ FILL DEPTH ABOVE COACH <br /> BED/TRENCH TRENCHES <br /> DIMENSIONS <br /> MANIFOID PUMP MAN[FOI.D DISTR PIPE MANIFOLD MATE DIAL NO UISTHOI STE PIPF DISTHIBUT ION PIPE MATERIAL&MARKING <br /> ELEV. ELEV OIA ELEV PIPES DIA <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SI(E HOLE svnclrvG OHILUDCrnnIECIIv 1OVER MATFRIAL VERTTCAI I IF T CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> DYES [:]NO OYES ONO <br /> COMMENTS0: MARKERS. OBSERVATION WELLS NUMBER:OP'S ' PROPERTY WELL BUILDING. <br /> FE£7 FROM LINE. <br /> ❑VES [:]NO ❑VES E-]NO NEAREST— <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> $IT:NAtUHE A� TITLE <br /> �-- <br /> DI LHR SBD 6710 (R.01/82) ��ygls.YinAla�f�/ q9t�L'-G�/-sl-yam. <br />