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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 El ALTERNATIVE slate Plano.Number: <br /> of aaalsneal <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER .��� 555ADDRESS OF PERMIT HOLDER � / <br /> INSPECTION ATE <br /> BEN thi C (� sti�aiw <br /> �:)OSN ST REF.PT. <br /> CH MARK(Permanent refers SC IBE FERENT FROM PLAN'. REF.PT. SEE CELEEVV <br /> G <br /> Al <br /> Nome of P mbar'. MP/MPRSW No.'. Cou nllary Permlf Number: <br /> SEPTIC TA K/HOLDING TANK: <br /> MANUFACTURER'. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> (DED: PROVIDED <br /> TY <br /> _ <br /> /�/Jl/./•� VES ONO DYES ❑NO <br /> BEDDING: IA.'. -VEMTMAT HIGN WATE NUMBER OF ROAD: 'T PROPERTY / WEL .1 BUILDDIINNCP'. VENT TO FREBH <br /> 4 ALARM. r /� LINE'. 1 ( AIRINLET'. <br /> p —I-- FEET FROM <br /> OYES O Ll ES NO NEAREST V r <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY PUMPMODEL. PUMPISIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED'. <br /> DYES ❑NO ❑YES ONO I ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROL5 UPEHAIUNAL: NUMBER OF PROPERTY WELL'. BUILDING: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE. AIR INLET: <br /> PUMP ON AND OFF) ❑VES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH: DIAMETEfl. 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 INSIUE DI A.. #PITS'. LIQUID <br /> BED/TRENCH I /fl /-NLI � TRENC S. MATERIAL: PIT DEPTH'. <br /> DIMENSIONS ``VVI �f/• (/ <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERI No.DIsrH. NUMBER OF PROPERTY N(E�.L BUILDINCy V NTTOFRESH <br /> BELOWPIPES It ABOVE COVER' ELEV.INLET'.ELEV.END'. qq�� PIPES- I AMINLET <br /> / d�H f���f d� FEET FROM <br /> L� ((// 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 /> DYES ONO <br /> OIL COVER ITEXTURE'. PERM ANENT MARKERS'. OBSERVATION WELLS <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OV ER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED: SEEDED: MULCHED: <br /> CENTER. EDGES. <br /> DYES ONO ❑YES ONO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: - <br /> WIDTH: LENGTH. NO.OF LATERALSPACING'. 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. DISTRIBUTION PIPE MATERIAL&MARKING <br /> . <br /> ELEV.. ELEV: DIA.: ELEV.'. PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE. HOLE SPACING'. DRILLED CORRECTLY: COVER MATERIAL'. VERTICAL LIFTCORRESPONDS TO APPROVED <br /> INFORMATION PLANS. <br /> DYES ❑NO OYES FIND <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> TTI�3,$ <br /> OYES ONO OYES ONO NEAREST <br /> 07 11 9,2 <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. LES. <br /> SIG TORE-. <br /> DILHR SBD 6710(R.01/82) v ��� <br />