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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> MADISON,,WWI 53707 <br /> P.O.BOX BUREAU OF PLUMBING <br /> CONVENTIONAL ❑ALTERNATIVE Bt ale Pl an 1l.o.Namper. <br /> IIt <br /> L1Holding Tank ❑ In-Ground Pressure ❑Mound aeaiynee <br /> NAM OF PERMIT HOLD oADDRESS OF PERMIT HOLDER INSPECTION DATE. <br /> J 7a/ /u/ <br /> EIVICH MARK(Permanent releren po,ntl DESCRIBE IF DIFFERENT FROM PLAN `* REF.PL ELEV.'. CST REF.PT.ELF V. <br /> Nme of Plmber. . )v / MdP/MPRSS`N <br /> � <br /> $anlary Pemt Nmpet <br /> SEPTIZ TANK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAPACITY TAZ_FRDTAD <br /> OUTLET ELEV WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED. <br /> YES ❑NO ❑VES NOBEDDING. VENT DIA.. VENTM AHLAHRMATEH MBPROPERTY WBUVENTTE FRESN❑VES I�NO C FEET F `INE _/ AIR Iry LET❑VES ❑NO NEARE30 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LI DVIU f:PPACITv PVMP MODEL PVMPrSIPHON MAN5111UIREH WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED. <br /> EYES ❑NO [:]YES ❑NO DYES ❑NO <br /> GALLONS PER CYCLE: PUMP AN.CONTROLS OPERATIONAL NUMBER OF PHOPERTv WELL BUILDINI, I vENr TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM INE Al.INLET <br /> PUMP ON AND OFF) 11 YES El NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FOflCE LENGTH DIAMETER MATERIAL ANO MARKING <br /> or excavation, (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> wlprH LErvGrH NO.of DISTR PI ESPACING COVER INSIDE Dlq SPlrs uoulD <br /> BED/TRENCH / //,, / TRENCHES ?ITE?tb PIT DEPTH. <br /> DIMENSR]INS ,� .,� J` �j / / <br /> GRAVEL DEPTH FILL DEPTH UISTH PIPE DISTR PIPE DISTR.PIPE MgTERIAD .DISTR NUMBER OF PROPERTY BU LDING. VENT TO FRESH <br /> BELOWPIPEPT ABOVEl/vER Et Fv INIZET ELE N�7 PIPES? FEET FROM LINE,�j J� AIR IrvLEr <br /> . 0 V�I a –��I f/ �—_ o/ NEAREST / <br /> MOUND SYSTEM: <br /> IF <br /> Mound site 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 /> ❑YES ❑NO <br /> SOIL COVER TEXTURE PERMANENT MAHKERs DRSERVAnDN WE U S' <br /> ❑YES ❑NO DYES_ ❑NO <br /> 7777T77== <br /> EPTH DV FR TFENCH'BED DEPTH OVER TRFNCH.BED DEPTH OF TOPSOIL Sf1DDE0 SEEPED MVLCHEO <br /> CENTER EDGES <br /> ❑VES ❑NO ❑YES ❑NO DYES ENO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH NOENCHES.O OF LATERAL SPACING GRAVEL DEPTH BELOWPIPF 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. DIA. ELEV. PIPES OI A.. <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COV ER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> DYES [:]NO DYES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBEROF PROPERTY WELL'. BUILDING. <br /> FEET FROM `INE' <br /> ❑VES 11 NO ❑VES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> slc E TITLE <br /> DILHR SBD 6710 (R.01/82) <br />