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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 <br /> locingTank <br /> ONVENTIONAL ❑ALTERNATIVE Btate PlanIM,Number <br /> ElIn-GroundPressure ❑Mound (11 a namee) <br /> NA OFhPERMIT HOLDER,,,, ADDRESS OF PERMIT HOLDER'. INSPECTION DATE <br /> ri 8-.s --x <br /> BENCH MARK Permanent inference P-mul DESCR BE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.'. <br /> I <br /> 0 XT-;w t.-, , �G 1e.Z <br /> HOD I <br /> Nam of Plumber MPI SW No. County: Ben'nery Permit NumEer'. <br /> l0 1375 <br /> SEPTIC TANK/HOLDING TANK: If 11 <br /> MANUFACTURER'. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> TMC�q -y �I PROVIDED: PROVIDED: <br /> ,/ C /J�Zi / C/ MYES ❑NO DYES ENO <br /> BEDDING: VENT DIA.: VENT MAT L.: HIGH WATER NUMBER OF ROAD: PROPERTY WE L BUILDING: VENTTOFRESH <br /> ALARM: FEET FROM I LIN / /`f > / AIR INLET'. <br /> OYES ONO � [:]YES ONO NEAREST <br /> DOSING CHAMBER: L <br /> MANUFACTURER: BEDDING'. LIQUID CAPACITY. PUMP MODEL'. PUMPISIPHON MANUFACTURER: WARNING LABEL I LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> OYES ONO DYES ONO I DYES ONO <br /> GALLONS PER CYCLE: vuMPANO CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. <br /> PUMP ON AND OFF) DYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing LENGTH' DIAMETER: MATERIAL AND MARKING <br /> or excavation. IIf 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 /> �.wA WIDTH LENGTH: NO.OF DISTR.PIPE SPACING'. COVERBED/TREINSIpE DIA.'. #PITS'. LIQUID <br /> DIMENSIONS ) TR EN`HES. // MAT AL: PIT DEPTH: <br /> DIMENSIONS / 4/ <br /> GRAVELDEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DISTR. NUMBER OF PROPERTY V BUILDING'. NT TO FRESH <br /> BELOW PIPESj- BovE c,/ER: ELEV.INLEt ELEV.ErvD: PIPES'. FEET FROM LIrvE. _ i AlqR Iry LET <br /> (O .,2<F PVC J NEAREST—► <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 /> ❑VES [:]NOmeets the criteria for medium sand. TIONS MEASURED. <br /> OIL COVER ITEXTURE'. PERMANENT MARKERS: OBSERVATION WELLS <br /> 1:1 YES ONO ❑YES 1:1 NO <br /> DEPTH OVER TRENCWBED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL. SODDED' SEEDED' MULCHED. <br /> CENTER. EDGES. <br /> DYES 1:1 NO I DYES 1:1 NO ❑YES NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH'. LENGTH: TRENCHES'. LATERALSPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.: ELEV: DIA.: ELEV.: PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL'. VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS. <br /> ❑YE ❑NO OYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS- NUMBER OF PROPERTY WELL: BUILDING'. <br /> FEET FROM LINE' <br /> DYES NO DYES ONO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE, / TITLE: <br /> DILHR SBD 6710(R.01/82) "Z '-«�� ' - �1- -` C� '�. : <br />