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REPORT ON INSPECTION OF SANITARY PERMIT # Da/�✓1 LJ <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2 D-ate of Inspection <br /> �° . S 7--27- ,Y/ <br /> Name, Address,/ IZense��o L in a ing p umber � o �� Time of Inspection <br /> Tl sLC� a Z 6 G <br /> � I <br /> (3)INSTALLATION CONSISTS OF: Septic Tank ❑ Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit eepage Bed ❑ Holding Tank [] Fill System <br /> T4j� (Permanentreference Point) Describe: <br /> El� of vertical reference point: 16-0 Slope at site: �a <br /> (5)MATERIAL AND DEPTH OF SEWER: ! p(fG . <br /> (6)SEPTIC TANK: Manufacturer: Lcl� Liquid Capacity: <br /> Tank Inlet Elevation: Tank Outlet Elev: Q 7 6 <br /> # ft to lot or property line: ) l OG # ft to well : �2_ $ ` <br /> (])DOSING TANK: Manufacturer: # of gallons : <br /> # of gallon pump set for a cycle ns ; total capactiy of distribution <br /> lines gallon; size of Pum head; gallon per minute ; <br /> horsepower ; brand a of pump a del number <br /> Is the warning device installed? []YES ❑NO Wired? ❑YES ❑NO <br /> 8 HOLDING TANK: Manufacturer of gallons <br /> construction ; depth to the gDyzr,I ft; If septic tank is <br /> being used are baffles removed? ES 0; ft from residence; <br /> ft from well ; ft from line. Type of warning device <br /> Is the warning device installed? YES , fired? []YES [] NO; <br /> Locking device on cover? []YES ❑ N0; Diameter of vent and material > <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: its; ft diameter; ft liquid depth; <br /> ft to residence; ft to ft to property line; <br /> ft to ordinary high water mar la r stream; ft to edge of slopes <br /> greater than seep pit inlet pipe- vation ft; bottom of <br /> seepage pit elevation ft. <br /> (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; <br /> 70 , lineal feet tile; _zM ft to residence; �TQ ft to well ; 66I ft to lot or <br /> property line; && ft to ordinary high water mark of lake or stream; �(Aft to edge <br /> of slopes greater than 20% falling away toward lakes, water courses or drainage ditches <br /> Elevation of tank discharge line entering bed 97 ft. _ <br /> 11 SEEPAGE TRENCH: Total le th of seepage trench ft; width ft; <br /> tile depth ft; ft to well ; ft to ordinary high water mark of <br /> lake or stream; ft to e f es greater than 20% falling away toward lakes , <br /> water courses or drainage ditche ion of tank discharge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH ?, r3.YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES ONO Floodplain? []YES NO <br /> DILHR-SBD-6095 N.0 /8 <br /> Signature of Inspector <br />