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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 �y�,},{{ <br /> CONVENTIONAL ❑ALTERNATIVE s1a1eP1a�LD.rvllmnel <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound 111 afvP^eBl <br /> NA OF PERMIT HOLDEP, DDRESS OF PERMIT HOLDER INSPECTION DATE. <br /> 7 / ny 3 Y-N <br /> BENCH MARK IPermanem relelence Pom00E5CRl DIFFERENT FROM PLAN REF PT.ELEVCSTREF PL ELEV <br /> Name o1 PI-1PIr. MPIMPRSW No Cnunly 1,No—Number <br /> a 71y 9 (/a 3P/ <br /> SEPTIC TANK/H LDING TANK: <br /> MANUFACTURER LIQUID CAPACITY TA NK INLET ELFV TANK oUTLFT ELEV. WARNING LABEL LOCKING COVER <br /> / PROVIDED PROVIDED <br /> W P, J 6) DYES ❑No ❑YES ONO <br /> BaoolNc rnor of A. xEnT Mnn HWATE" NUMBER OF Rono PROPERTv wEu euumlvG varvr rO FRESH <br /> �� AlLAnM FEET FROM d� uNE 1 / /,F� Iaq INLET <br /> YES []NO <br /> G ❑YES ❑NO NEAREST �J Tr' 3Q(,I 715 L' <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING IID UID CAP,L I1V 111MP MIED,I PUMP.SIPHON MANU141:11111111 WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED. <br /> ❑YES ❑NO I DYES ❑NO DYES LINO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PH11P11rtv w1u BUILDING VENT TO FRESH <br /> (DIFFERENCE BETWEEN 'FEET FROM LwE AIR INLET <br /> PUMP ON AND OFF) EYES ❑NO NEAREST-- <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing IIN'TH ff"I1111 11ATIHIAI Aw1MAHKING <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 /> Twm'HpLENero No Or D1sT11 PIPE Svna NIDA ucwD <br /> SEDfTRENCH 1EN: MAv111uAPIT <br /> � 3 fr rATs <br /> On <br /> EZI <br /> GRAVE L D17PTH FILL DEPTH 1115111 P11'1 UISTH PIPE OISTR PIPE MATERIAL NO 015111 NUMBER QF.. PROPERTv WELL BUILDING vENTTO FRESH <br /> BELOwv1P/ES// ABOVEcDVEH1 EIIV IN1I1 ELEV Lvu �. p vIP1 :FEET FROM LINE 1' 3a I AIR Iry LET <br /> l;� f- ,/ NEAREST 30U 3D <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 /> ❑VES ONO <br /> SOIL COVER ITE.TLRI 11 IMA ru N1 MAHK1 RS Du51e1A11DN W1uS <br /> ❑YES E]NO 11 YES ❑NO <br /> DEPTH OVER THENCE'a E O DEP TII LIVE R THENCE'RE 0lPn1 ul lurSuu Sl luulu u MULCHED <br /> CENTEH EDGES <br /> LJ51101 <br /> YES. ENO ❑VES ❑NO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> 'WIDTH LENen1 NO OF LATE HAL SPAcmr; 'a+nvLL DEvn1 RE Luw PIPS F ILL DEPTH ABOVE COVE <br /> BED/TRENCH ' TRENCHES <br /> DIMENSIONS <br /> 'MANIFOLD PUMP MANIrDLII DI$TR.PIPE MgNIFDLO MATERIAL ND D151H DI$TN PIPf IIIST111501 ION PIPE MATERIAL&MARKING <br /> ELEV. ELEV DIA ELEV. PIPES DIA <br /> ELEVATION AND <br /> DISTRIBUTION ROLE SIZE HOLFSI INh CHIEF LD FOHRFCIIV CIIVFR MATE V IAL VERTICAI LIF r CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> DYES ❑NO ❑VES ❑NO <br /> COMMENTS: PERMANENT MARKERS OBSERVATION WELLS. NUMBEAI'OF PROPERTY WELL. 6UILUING <br /> FEET FROM'. u0C <br /> DYES ENO ❑VES ❑NO NEAREST--;." <br /> r> /; C5 c'le <br /> D <br /> 9 ,0 6,, vG,%c/ L <br /> ��E;-� �Ot^,",.�� Sko,.,. oL.� So,/ftsf6c�t c(-,f.j�` <br /> MCN if,41_ <br /> Derr. eleHfk�-A, ArW- ILO sAI-J- DI7 <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIG/N U TITLE <br /> DILHR SBD 6710 (R.01/82) 1.����—� <br />