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l0-tI-�Y <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR "—HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> BUREAU OF PLUMBING <br /> P.O.BOYO 7969 <br /> MADISON,WI 53707 <br /> j4CONVENTIONAL ❑ALTERNATIVE IState Plan l.D.Number: <br /> In assigned) <br /> ❑Holding Tank ElIn-GroundPressure 1:1Mound <br /> NAME OF PERMIT HOLDERADDRESa OF PERMIT HOLDER INSPECTION DATE: ^� <br /> BENCH MARK rmanen 1 polntl DESCRIB�E nIFI DIFFERENT FROM PL N: r x� / } i ) /i.»P;. REF PT ELEV: CBT REF.PT.ELEV.: <br /> Santary Permit Number <br /> Name of Plumber / MP/MPRSW No.: CounryO'. / '. ��• <br /> 1 mss- ' 1-2.1 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LAB L LOCKING COVER <br /> 141/ �J --yy , DED: PROVIDED'. <br /> !SG' /r��—J �/° P O IYES ONO ❑VES ONO <br /> '. VENT DIA.' VENT MATL.: HIGH WATEH NUMBER OF ROAD: PROPERTY WFh1:..,T BUILDING: VENTTOFRESH <br /> BEDDING <br /> r� ALARM' FEET FROM LINE: �-1 AIR INLET: <br /> ❑YES NO G- OYES [:]Nn NEAREST "Z�! -ye J'e/ ' / <br /> DOSING CHAMBER: - <br /> MANUFACTURER BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER- PROVIDEDRNING LABEL PROVIDED OVER <br /> OYES FIND [--]YES ONO OYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBEROF PROPERTY WELL: BUILDING: VENTTOFRESH <br /> (DIFFERENCE BETWEEN INE <br /> FEET FROM AIR INLET'. <br /> PUMP ON AND OFF) ❑VES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH: DIAMETEH'. MATER IAL AND MARK ING'. <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 /> WIDTH / LENGTH: NO.OF DISTR PIP-SPACING COV R INSIDE DIA.: #PITS: LIQUID <br /> BED/TFERCH• ) / TRE/CHEST /� MAT RIAL PIT DEPTH: <br /> DIMENSIONS / <br /> RAVEL DEPTH FlLL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO DIS NUMBER OF PROPERTY WELL: BUIDING: VENT TO FRESH <br /> BELOW PIPES- ROVE COVER' ELEV. NLET'.ELEV.END: PIP LINE l / AIR INLET: <br /> / EV q C' 7 • _� FEET FROM y i "T-. �, 7 <br /> J NEAREST � '� <br /> MOUND SYSTEM: <br /> Mound sitg„plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <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 /> OYES ONO PERMANENT MARKERS'. OeSERVATION WELLS. <br /> I-COVER TEXTURE'. <br /> OYES ❑NO DYES ❑NO <br /> DEPTH OVER TRENCH/BD DEPTH OVER TRENCH/BD DEPTH OF TOPSOIL: SODDE SEEDED: MULCHED: <br /> CENTER. EDGES: <br /> F1 YES ONO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIOTH: LENGTH. NO.OF LATERALSPACING'. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER'. <br /> BED/TRENCH TROCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PI E DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.. ELEV: DIA.'. ELEV.: PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLESIZE'. HOLE SPACING. DRILLED COR RECxLY: COVER MATERIAL. VERTICAL LIFT-CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> OYES <br /> ❑NO —]YES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> OYES FIND ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIG T��E'. TITLE: <br /> DILHR SBD 6710(R.01/62) <br />