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. . . Ate. /If III , � LZo i <br />'RTMENT OF INDUSTRY, - I NSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOK 7969 BUREAU OF PLUMBING <br /> MADISON,AT 53707 <br /> ❑CONVENTIONAL ❑ALTERNATIVE <br /> ❑Holding Tank ❑ In Graund Pressure ❑Mound <br /> PAP F Ti aENMIT ICI °xr25°I IF FAR Pro IR'. INSPECTION <br /> 7°nl[: <br /> AE <br /> Ex 'A-'PI-11 D[sLRIaER.I,I EmxI I IIIA 1L.E I LEE.PT.ELF1 JIST OLE.IT ILI'. <br /> a. <br /> VIA <br /> ANI- <br /> —Is I.-TA, MPRswx� rlroci/oP .M� I rv.m 3 <br /> SEPTIC TANK/HOL NG TANK: <br /> uuE x. EL FIRmvEl <br /> N�1e.$Q1 ursu�u cnP^r.. uNaN�E'�cv. In c [ XNV ES 4Br0i POYES ONO <br /> rT ou.. xr man. lomx waTEu/ 51�r NUMBE90F J' o L <br /> sOVES lN0_ — nanl FEET FROM A)�OOI ix�En TL��T� <br /> ❑YES ❑NO NEAREST—�. ' I.�Q I Q <br /> DOSING CHAMBER: <br /> CLUIACT"'I" JUIDI. WICIIELlTr IPAITEL Ia.SIPx°x Anm W a FILED, L LIXING <br /> nEOvtI <br /> rvOEO�p PROVIDED. <br /> DYES ONO ITE PROVIDED <br /> ONO ❑YES ONO <br /> GALLONS PER CYCLE P axa IONTOOLS OPERATIONAL: NUMBER OF ry L ml <br /> (DIFFERENCE BETWEEN FEET FROM E uv. <br /> PUMP ON AND OFF) ❑YES ONO NEAREST—'Lx <br /> SOIL ABSORPTION SYSTEM.Check the soilmoistule a TThedem h olplowi ng FORCE I.nl mrtw wla ..uumnlLirvl. <br /> or exesIT. (1f snll can be rolled ins.a w cansllucti.n shall cease until MAIN <br /> The soil isldr,a .ugh lO c°ntinue.l <br /> CONVENTIONAL SYSTEM: <br /> BEDRRENCH T NCIx T lIPnC."' IFIUL mL.IA Is uowD <br /> DIMENSIONS V r L '1 5 / Nc�[s I� r PIT L. T <br /> Ow r, rnl / I"ED t J NUMBER Of <br /> .Pip ISIR.PnE m.T/uiaL, ° O FEET FROM Ps w[u / el ne Tor/Es <br /> rEs� IrvIxLE� Ei �e `I NOF., <br /> NEAREST—vluxi v r� u,°�a. nil�O <br /> el <br /> MOUND SYSTEM: o//✓ J U/5 <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <br /> andfurrowsthrown u pslope: 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 ITILJFRF JIFERSO M.R.Exs 1—TRECwELLI <br /> ❑VES ❑NO ❑YES ONO <br /> nx IIINICRAII. A rs uvEa IOENC'IDE IxaE IOPaaLOE1 oto oa. <br /> s°u OYES CNO OYES ONO (DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH <br /> A'o'" <br /> nhaTT1 DoxolEs. EIALSvaan VrLu[PrRaLL.w PUr. L DEPT'1bTi C°vLI. <br /> DIMENSIONS <br /> .Pe E NROL.MATERIAL <br /> ° E IT.aM ZION PILL MATERIAL ii INTO <br /> ELEVATION ANDEL <br /> V. v.. Prs II <br /> DISTRIBUI ION <br /> IN <br /> FORMAT IDLEsenaN u[u LDRRLpIr LIL NET <br /> x FARE CENEL SPONDS T.PARADVED <br /> DYES ONO E DYES CNO <br /> COMMENTS: MexENI M.Ians. ExaanoNwELLs. NUMBER OF PRNPERIr u. LDmG. <br /> DYES ONO DYES ONO NEARESDYES ONO DYES NEARES�i <br /> Sketch System or Retain in county file for audit. <br /> REVOT.Side. <br /> \D I LHR SBD 6710(R.01/82) <br />