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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 DALTERNATIVE I State Plan l.D.Number <br /> (11 xsi9nedl <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT MOLDERADDRESS OF�HOLDER INSPEC710N DATE <br /> 2zlld"wy: <br /> BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV CST REF.PT.ELEV/ <br /> /& / 4�1 <br /> Nam.,nl Ii MP/MPRSW No. Courcy Sanitary Permit Number <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAVPACITY TANK INLET ELEV. TA47 L_ ELS`. WARNING LABEL LOCKING COVER <br /> �/s ! PROVPROVIDED <br /> YES ONO ❑YES ❑NO <br /> BEDDING. MFR DIA. VENT IIIA— HIGH WATER NUMBER OF ROAD. PROPERTY WELL: BUILUING. VENT TO FRESH <br /> /I a— - AIIAQ"4 FEET FROM �j L'� LIrvE .r7 r � AIR INLET <br /> VES ❑NO y ❑YES ONO NEAREST_ :. _ l `7 12.6 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LIQUID CAPACITY vUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED: <br /> DYES ❑NO I DYES ONO ❑VES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATION AL NUMBER OF .PROPERTY WELL BUILDING VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) EYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing ,I N.„TII InAMETER 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 NO OF DISTR PIPE SPACING COVER INSIDE DIA -PITS LIQUID <br /> BED/TRENCH ' f TRENCHES MAT RIALPIT DEPTH- <br /> DIMENSIONS 19 1 <br /> rIHAVEL DEPT” FILL DEPTH PIPf DISTR PIPE DISTR.PIPE MATERIAL O DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH <br /> ABOVECOVERJOISfT <br /> EITVV INL�t ELEV END' N �) PIPES. FEET FROM LINE. ` AIR INLET <br /> ✓ 7 r3 (! 3 NEAREST d / S S 23 <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 /> DYES ONO <br /> SOIL COVER TF.TURE PERMANENT MARKERS OBSERVATION WELLS <br /> DYES ONO DYES ONO <br /> DEPTH OVER THE N(:H BED DEPTH OVFH TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES <br /> DYES ❑NO DYES ONO OYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH TNO OFRENCHES: LATE RAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD. DISTR.PIPEMANIFOLD MATERIAL NO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELEV ELEV EIA 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 /> ❑YES El NO OYES ❑NO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS-. NUMBER OF PROPERTY WELL. BUILDING. <br /> FEET FROM LINE <br /> ❑YES ONO OYES 1:1 NO NEAREST <br /> cotA <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE TITLE <br /> DILHR SBD 6710 (R.01/821 1 _401i <br />