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U- I(S- `6k --,k :�o <br /> 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 ❑ALTERNATIVE State Plan I.D.Number. <br /> Ill assigned) <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NgME O PERMIT HOLDER: gDDRE S OF PERMIT HOLDER(: INSPECTION DA11 •4 <br /> r L, �,r `a )s / Lir/ <br /> BENCH MARK(Permanent refer¢ -a point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: JCSTREIKPT.ELEV.'. <br /> Name of lumber. MP/MPRSW No.'. Count / Sanitary Permit Number: <br /> SEPTIC T NKMOLDING TANK: <br /> MANUFACTUREa LICYIRCnGACITY: TANK INLET ELEV.: TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> ✓ PRO (DED: PROVIDED: <br /> ES ❑NO VES NO <br /> BEDDING: VENT DIA.: VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY / WELL: BUILDING: VENT TO FRESH <br /> ALARM'. FEET FROM / u E- C��/Y ` AIR INLEr: <br /> DYES NO I gPES—BNB NEAREST � / f/V <br /> DOSINGCI4AMBER: <br /> MANUFACTURER REDOING: LIOUID CAPACITY'. PUMP MODEL: PUMP/SIPHON MANUFACTUREfl: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES ONO OYES ONO ❑YES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING'. VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET: <br /> PUMP ON AND OFF) ❑VES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing LENGTH: DIAMETER' MATERIALAND MARKING. <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> MAIN <br /> the soil is dry enough to continue.) <br /> ONVENTIONAL SYSTEM: <br /> WIDT LENGTH: NO DISTR.FIRESPACING: COVER INSIDE DIA.'. #PITS: LIQUID <br /> BED/TRENCH JA�l TFNCHES: A ER IAL: PIT DEPTH'. <br /> DIMENSIONS <br /> RAVELDEPTH FIL D H DIS .PIP OISTR.PIPE OISTR.FHE MATEfl IAL Into.DISTH. NUMBER OF PROPERTY WELL UILDING: V NTTOFRESH <br /> BELOW PIPES BO E jiQvFR: ELEV.INL ELEV.END: PIP - FEET FROM LINE. / �� A LE <br /> ti / all NEAREST= �� <br /> MOUNDNaar SYSTEM: vkoq <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <br /> and furrows thrownupslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> E]YES ONO <br /> OIL COVER TEXTURE-. PERMANENT MARKEflS: OBSERVATION WELLS. <br /> I ❑YES ONO DYES FIND <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. SEEUED: MULCHED: <br /> CENTER EDGES: <br /> DYES ONO DYES 1:1 NO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH'. LENGTH: NO.OF LATERALSPAOING GRAVEL DEPTH BELOW PIPE'. FILL DEPTH ABOVE COVER'. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMPMANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DIST.. OISTR.PIPE DISTRIBUTION PIPE MATERIAL MARKING <br /> ELEV.. ELEV.. DIA.'. ELEV.: PIPES'. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE: HOLESPACING: DRILLED CORRECTL COVER MATERIAL: PLANS LI FT CORRESPONDS TO APPROVED <br /> DYES ONO F-1 YES []NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'. <br /> FEET FROM LINE: <br /> DYES ONO ❑YES ONO NEAREST <br /> SketchSystem o R tain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE <br /> DILHR SBD 6710(R.01/82) <br />