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�o -,, CC- <br /> DEPAi^TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS I <br /> P.O.BOX 7969 BUREAU OF PLLUMBUMBINN <br /> G <br /> MADISON,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE $Me PM LD.Number. <br /> 111 auibnadl <br /> 171 Holding Tank ❑In-Ground Pressure ❑Mound <br /> NAME OF PERM IT HOLDER: ADDRESS OF PERMITS HP LO ER: INSPECTI NDATESte^ r� <br /> ( 0 � � r� k i Ica �lu <br /> � �� � <br /> aFNCH MARK IPerrrrrwnl 10..x MIMI DESCR IBE I FEREFT FROM PLAN: REF.PT.I LEV.: CST REF,PT.ELEV. <br /> D 0 �7F <br /> Norm of Plumb MP!MPRSW Nu.. CbumV: SanitrY P me Number: <br /> Lh <br /> SEPTIC TANK/H <br /> MANUFACTURER: �A LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV ARNING LA LOCKING COVER <br /> T/ / c �� pqp '�f� PROVIDED: <br /> 2 �G 'I^iA'yYE ONO DYES ONO <br /> BEDDING V ENT DIA.: VENT MATL.- HIGH WATER NUMBER OF ROAD' ROPERTY W BUILDIN VENT TO FRESH <br /> ALARM: a�0 I LIIN �/ AIRINIFT: <br /> 61 FEET FROM �- <br /> ❑YES NO ❑YES CJN NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER. BEDDING'. LIQUID CAPACITY: PUMP MODEL PUMPISIPHON MANUFACTURER WARN( (LABEL LOCKING <br /> OVER <br /> PROVIDYES ❑NO I I ❑Y ONO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY W LL. BUILDING. VE N'U ESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE <br /> PUMP ON AND OFF) ❑YES NO NEAREST <br /> Sol L ABSORPTION SYSTEM.Check the sail moisture at the depth at plowi ng LENGTH DIAMETER MATE ALANnMARKING <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> MAIN <br /> the soil is dry enough to continue.) <br /> CONIVENTIONALSYSTEM: <br /> WIDTH: / LE M NO.Of DISTH.PIP SPACING VER INSIDE OIA_. MPITS. DEPTH <br /> BED/TRINEF o / THE 6HFS ) M IAL PIT ILIQUILI <br /> DEPTH <br /> DIMENSIONS f D J4r (G <br /> GRAVEL DEPTH ILL DEPTH DI R.PIPE DISTR,PIPE ioisTH.PIPE MATERIAL NO.DIS - NUMBEROF R TY ROIL IN VENT TO FRESH <br /> BELOW PIPES BOV COVER E_E�LET ELEV.END: �� PIPE, FEET FROM LINE - IR NLET <br /> Y'l1 Y �!}7E //J NEAREST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAMOFSYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERIIESIDE-SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEA SURED. <br /> DYES ONO <br /> IL OVER TEXTURE' PERMANENT MARKERS: BSERYATION WELLS <br /> DYES ❑NO OYES ❑NO <br /> D EPTH OVER TRENCH;BEO DEPTH OVEH TRENCH; ED DEPTH OF TOPSOIL: ODOED: SEEDED'. MULCHED <br /> CENTER. EDGES' <br /> DYES ❑NO EYES EINO I OYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH: O.Or LArERALSPACING. GRAVEL DEPTH BELOW PIPE LL HABOVE COVER <br /> BED/TRENCH TRENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUM MANIFOLD DIBTR.PIPE MANIFOLD MA ERIALr NO.DISTR. DISTR. DISTR UTI ON PIPE MATERIAL MARKING <br /> ELEV.. ELEV.' DIA.. ELEV.: PIPES.- IT <br /> ELEVATION AND <br /> DISTRIBUTION PERT AL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION HOLE SIZE: OL'SPACING: ILLEO CORRECTLY COVER MATERIAL: <br /> PLAN [DYES❑NO [DYES ONO <br /> COMMENTS: ERMANEN AIi KER : OBSERVATION WELLS. NUMBER OF LIN ERTV WELL: BUILDIN <br /> FEET FROM <br /> DYES ONO ❑YES El NO NEAREST <br /> Sketch System on Retain in county file for audi . <br /> Reverse Side. 1 L <br /> SIGNATURE <br /> DILHR Sao 6710(R-01/82) <br />