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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 /> CONVENTIONAL ❑ALTERNATIVE State P1a^1.o.N,mBer. <br /> 1:1 Holding Tank ❑ In-Ground Pressure EJ Mound <br /> N E OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION DAT <br /> NLH MARK Permanent relerente Ammil DESCRIBE IF DIFFERENT FROM PLANREFT LE V,- CST REE.IT ELEV <br /> /Do Sao, <br /> Name Plum MP/MPHSW An Sa PO,Permit Num Enr <br /> 3a y > 7966 /a s 3 3 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIOU IO CAPACI TV TANKINLETELEV TANK OUT LET ELEV WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED <br /> OYES ONO OYES ❑NO <br /> BEDDINGVENT DIA.. VENT MaII HI(�II WATT NUMBER OF ROAD. PROPERTY WELL S U ILOING. (VENT TO FRESH <br /> nLAllnl FEET FROM LINE AIR INLET <br /> ❑VES ❑NO ❑VES LINO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LIQUID('APA(ITV PUM []DEI PUMP.SIVIION MA Al I11HFH WARNING LABEL LOCKING COV ER <br /> PROVIDED PROVIDED. <br /> atill <br /> ❑VES NO YES ONO OYES ONO <br /> GALLONSPER CYCLE: PUMP AND CONTROLS OPERATIONAL NUM6ER OF` PROPFHTv wEu euILD1NG VENT rO FRESH <br /> (DIFFERENCE BETWEEN _ NFEET FROM LWE aw INLEr <br /> PUMP ON AND OFF) YES C�NO NEAREST-3► 37� <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of ploveing "FORCEO <br /> . 1INn1 uM <br /> lAf nR aT <br /> NIHIAIANOMARKIN(1 <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until / n <br /> the soil is dry enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> WIDTH f LENGTH NO Or 01sIF P1PI SPAI:IN' COVEN wvuL FIA SPITS uoulD <br /> BED/TRENCH Q 1 IHINCTns / n1ArEI nc PIT DEFTH <br /> DIMENSIONS V 36 �/��s✓ <br /> L.11111 FILL DEPTH 1115111 PIPf UISTH PIPE DI$TR PIPE MATERIAL ND OIGIII NDMBEiR DF PROPERiV WELL BUILDING' VENT TO FRESH <br /> BFLOWPIP S7/ ABOVE mvEH E1 ry INLII EL[V Irvu r. �/ a�. 9 vPIS :FEET FROM uNE / C�,(I AIR INLET/ <br /> ,SB 01,Iq �U� :NEAREST— >s �DO D6 >Ieo <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 /> meets the criteria for medium sand. TIONS MEASURED. <br /> ❑YES ONO <br /> SOIL COVER TEXTURE PIHMANFIN n1A11 oBsu+vanON w f 115 <br /> DYES ❑NO _❑YES ONO <br /> DEPTH OVEN rHENCH BEO DEPTH OV CH INFNCH BE 11 II[4'TII III I(IPy1111 1(lllFf 11 SE I OF II MULCHEO <br /> CENTER EDGES <br /> ❑VES. ❑NO ❑VES ❑NO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: _ <br /> WIDTH LENGTH NO.OF LATERAL SPACIN(, GRAVEL DEPTH HE LOw PIP[ FILL DEPTH ABOVE COVER <br /> BED(TRENCH TRENCHES <br /> DIMENSIONS <br /> ]!MANIFOLD PUMP MANIFOLD DISTE PIPE MANIFOLD MATERIAL NO UISTH DISTH PIPE DISTHIBUT ION PIPE MATERIALS,MARKING <br /> .ELEV. FLEV CIA ELEV PIP" OIA <br /> ELE V AT:ION AND <br /> DISTRIBUTION.. <br /> INFORMATION AL HOLE SIZE ROLE SPACINo 0111LLLDCURREC.ILV COVER MATERIAL VVEARTICAL LFT CORRESPONDS TO APPROVED <br /> OYES LINO ]VES ONO <br /> COMMENTS! PERMANENT MARKERS. OBSERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING. <br /> c/ FEET FROM LINE. <br /> e OYES ONO ❑VES ❑NO NEAREST—fir_ <br /> JJ SS e7e <br /> Sw r*-,, ele -9,F /00.91 <br /> T6,G8 10% <br /> 0e, 1A 1614V <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> $IG Tll E TITLE <br /> DI LHR SBD 6710 (R.01/a2) D ^r ��" <br />