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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.SOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 ,,��//�-""�� <br /> VENTIONAL ❑ALTERNATIVE s,r1e 9l±n"li D.N—b" <br /> Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOL Efl. ADDRESS OF PERMIT HOLDER. INSPE,7N DATE- <br /> i syr o /'/7' <br /> UIENr MARK(P-man-, —0!DESCRIBE 11 DIFFERENT FgOMPANqEE PT.EOy. CST REF.PT ELEV <br /> Name.1 PlumberM PRSW N,, Lounry. S,,1,D,Pi,m,Numbe.'. <br /> o3d5l 07 %aOPP <br /> SEPTIC TANK/H LDING TANK: <br /> MANUFACTURER LIQUID CAPACI TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER <br /> �/�7 PROS` DED. PROM DED. <br /> W C p p w 9YES ❑NO norc5 — v0 <br /> BEDDING. VENT OIq. VENT MALL HIt1H WATER - MBER OF gpgp' Ilu PROPERTY WELL. BUILDING. VENTTOFRESH <br /> FEET FROM I LINE , X I AIR INL�EtT / <br /> YES ❑NO ❑YES ❑NO NEAREST7�U� <br /> DOSING CHAMBER: <br /> MANUFACTURER [DOING 11 10U111 CAPACITY PUMPM[)pEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROM DED PROVIDED. <br /> DYES ❑NO ❑VES ONO ❑YES ❑NO <br /> GALLONS PER CYCLE: Pumv AND CONTROLS OPERATIONAL NUMBER OF PROPERTY weu euHOING NT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. <br /> PUMP ON AND OFF) DYES [!]NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing LENGTH QIAMETEH MATERIAL AND MARKING <br /> or excavation. Of 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 INC OF DISTR PIPE SPgCING COVER INSIDE DIA #PITS LIOU10 <br /> BED/TRENCH /) ( G/ TRENCp ES / MATERIAL PIT <br /> DIMENSIONS j / <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIP' p15TR.PIPE DISTR.PIPE MATERIAL. NO DISTR. NUMBER OF PFU1"TY WELL BUILDING VENT TO FRESH <br /> BELOWPIPES ,/_ ABOV�F yovER ELEV INI'r ELEV Erv0 II PIPES FEET FROM LINE. AIR INLET <br /> NEAREST--Ol ��S ��o�� <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 ❑NO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TEXTURE PERMANENT MARKERS. OBSERVATION WELLS <br /> DYES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH BED DCPTR OVER FRENCH.BED nEPrH of TOvsoIL SOOOED SEEDED MULCHED <br /> CENTER EDGES <br /> ❑VES ❑NO ❑VES EI ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH TRENCHES. LATERAL SPACING. 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 /> ELEVATION AND <br /> ELEV. ELEV. pIA. ELEV. PIPES DIA.'. <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> vLgms <br /> ❑VES LINO PLANS <br /> ❑NO <br /> COMMENTS: PERMANENT MARKER& OBSEgVATION WELLS'. NUMBER OF PROPERTY WELL. BUILDING: <br /> FEET FROM LINE <br /> ❑VES ❑NO DYES ❑NO NEAREST <br /> A/e Sir, 6 tI Pla ( Ad— <br /> _T III <br /> d— <br /> _TG• IQm as. <br /> CS 7 C�ei� /y/prlL uuase�ES�e <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGN R TITLE. <br /> DILHR SBD 6710(8.01/82) / <br />