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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,W 153707 <br /> CONVENTIONAL ❑ALTERNATIVE 5,11e Plan 1.D.N„mber <br /> I I I aaa�Rn�l <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER /^� INSPECTION DATE <br /> All 1�5 <br /> BENCH MARK ennane�. relere-P Poiml DESCRIBE IF DIFFERENT FROM PLAN I REF.PT.ELEV.'. CST REF.PL ELE V.' <br /> 5-♦9M loo -W I /OU <br /> Namr nl Plumber MPIMPRSW N,. County. Sanitary Permit Number <br /> 6_79 <br /> S PTIC TANK/H LDING TANK: <br /> MANUFACTURER LIQUID CAPACI V. TANK INLET ELEV. TANK OUTLET ELEV.' WARNING LABEL LOCKING COVER <br /> o RpVIDED <br /> C/ <br /> �, S ���� � VES ❑NO DYES ONO <br /> BEDDING. VENT DIA.' VENT MATL. HALGAHRMWATER NUMBER OF ROAD' PROERTY WELL. ' BUILDING VENT TO FRESH <br /> FEET FROM ''nn INEq � `} AIR INLET <br /> 17rYES NO ❑VES ONO NEAREST O17o W�I'JP L. / / �� `^' <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDUING LIQUID CAPACITY Pl1MPMODEL PUMPISIPHON MANUFACTURER WARNING LABEL LOCK]NG COVER <br /> PROVIDED. PROVIDED'. <br /> ❑VES ONO DYES LINO I ❑VES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTHOLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) OYES ❑NO NEAREST—► <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing LENGTH DIAMETER 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 SPITS LIOUIp <br /> BED/TRENCH 7 7 / THE NCHES / MATER AL FIT DEPTH. <br /> DIMENSIONS / /tR �`' <br /> GRAVEL DEPTH FILL DEPTH DISTH.'ITT DISTR PIPE HDISTR.PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL BUILDING'. VENTTO FRESH <br /> BELOWP/5 ABOVE COVER EI Ev INIII ELEV END // (� PIPES FEET FflDM LINE. " F ♦ AIR INLET. / <br /> C �Ji 4T J- P NEAREST O —J O �•SO .!.5D <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 [:]NO <br /> SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS <br /> ❑YES [:]NO EYES ONO <br /> DEPTH OVER TRENCH BED DEPTH OVER TRENCH:BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES <br /> EYES 1:1 NO I DYES ENO ❑YES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BEDlTRENCH <br /> WIG TO LENGTH TNO OF RENCHES. LATERALSPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANI FOLD MATERIAL NO.OISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV. ELEV. DIA ELEV. PIPES DIA.'. <br /> ELEVATION AND <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLYMATERIAL DISTRIBUTION <br /> INFCOVER MTEVERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> EYES ONO [-]YES ONO <br /> COMMENTS] PERMANENT MARKERS OBSERVATION WELLS. NUMBER DF PROPERTY WELL. BUILDING'. <br /> FEET FROM LINE. <br /> El YES 1:1 NO El YES ENO NEAREST <br /> 9K,o� 9�aa P,IT'l. PS.. 3,,q <br /> � Ss;y Q 6 � <br /> 92q 91� <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNAT TITLE.E� <br /> DILHR SBD 6710 (R.01/82) { <br />