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7_zi .90 tz.aD <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HumAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 State Plan I.D.Number. <br /> CONVENTIONAL ❑ ALTERATIVE (If ass�yned) <br /> ❑ 1 0101 g Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDE : ADDRESS OF PERMIT HOLDER -7 <br /> C'" /_'%m. ._.. _ I INSPECTION DATE'. <br /> /Y1 i Cha a anto K -Par -L-L- o C <br /> BENCH MARK(Permanent re enc point)DESCRIBE IF DIFFERENT FROM PLAN: �I REF.PL ELEV.'. CST REF.PT.ELEV.: <br /> tun e2 > 4�� G7 <br /> Namelofflumbelr)) MP/MPRSW No.: County. Sanitary Permit Number <br /> FKJ K f()S 3 )�0 1 <br /> SEPTIC ANK/HOLDING TANK: <br /> MANUFACTURER'. / LIQUID CAWGITY: TANK INLET ELEV.: TANK OU LET ELEVr. WARNING LABEL LOCKING COVER <br /> e I _,)_e n�M��e�� ��a r ,�1 PROVIDED: PROVIDED: <br /> kjs' r ` 'I U YES ❑NO 11 YES 9NO <br /> BEDDING: VENT DIA.: VENT MATLHIGH WATER NUMBEROF ROAD: PROPERTY WELL: BUILDING VENT TO FRESH <br /> L ALARM: FEET FROM LINE: ��� AIR INLET'. <br /> ❑YES NO .{/ ❑YES ❑NO NEAREST—� 00 <br /> DOSING CHAMBER: 0" <br /> MANUFACTURER: BEDDING. LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL I LOCKING COVER <br /> PROVIDED: PROVIDED'. <br /> []YES ❑NO ❑YES ❑NO I ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET' <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST---* <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: UIANI I MATERIAL AND MARKING: <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH' LENGTH: NO,OFDISTR.PIPE SPACING: COVER INSIDE DIA.: SPIT$'. LIQUID <br /> TRENCHES <br /> BEDITRENCH //L( 'I TRENCHES' '"& � MA ERIAL PIT DEPTH'. <br /> DIMENSIONS 1 b � �— <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH <br /> BELOW PIPES: ABOVE COVER: ELEV.IN T' E ND'. PIPES: FEET FROM LINE Z' Z it AIR INLET <br /> IL <br /> �7a -3 NEAREST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVEfl j TEXTURE: PERMANENTMARKERS: OBSERVATION WELLS: <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED'. SEEDED. MULCHED'. <br /> CENTER: EDGES'. <br /> ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH' NO.OF LATERAL SPADING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> TRENCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PI PE MATERIAL B MARKING: <br /> ELEV.'. ELEV: DIA.: ELEV.: PIPES: DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> E]YES [--I NO I ❑YES ❑NO <br /> PERMANENT MARKERS OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> COMMENTS: FEET FROM LINE <br /> ❑YES ❑NO L ❑YES ❑NO NEAREST <br /> 3 �6�7 Se / <br /> 5-yf- 9A-„Ak <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIGNATURE: TITLE: <br /> SBD-6710(R.06/66) <br />