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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 s.,..elan LD.N�moar <br /> m erl,an�l <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PER IT.0 OF / /�PERMIT HOLDER INSPECTION DATE AOOR <br /> BELCH M7K P rmanem r111,1ence pomp DESCRIBE IF IFF NT FROM PLAN. REF.PT.ELEV.'. CST REF.PT.ELEV. <br /> u - Cl f. <br /> Nama 1 Plumber MP/MPRSW No. County S.H.I.rV Permit Numper <br /> SEP ICT / <br /> MANUFACTU R. LIDO ID CAPACITY. TANKINLETFLEV.. TANK OUTLET ELEV WARNING LABEL LOCKING COVER <br /> G �Q PROVIDED PROVIDED <br /> C> <br /> J_✓ - YES ❑NO LIVES ❑NO <br /> BEDDING VENT DIA.' VENT MATL HIGH WATER NUMBER OF ROAD' PROPERTY W�y� BUILDING VENT TO FRESH <br /> ALARM FEET FROM LINE�j, Vr ,. AIR INLET <br /> DYES YNO YES ❑NO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LInVID CAPACI TY PUMV M!)nEL PUMP/SIPHON MANUFACILIREH WARNING LABEL LOCKING LOVER <br /> O TY gg ''II PROVIDED PROVIDED. <br /> J <br /> DYES KNO Lf r`�Y I12YES ❑NO ❑YES ENO <br /> GALLONS PER CYCLE: PUMP AND corvrnoLs oPERAr1oNAL NUMBER OF FINE <br /> w L eulL.11,N�i, VENT TO FRESH <br /> (DIFFERENCE BETWEEN {' Q Q FEET FROM LINE I F n�/ AIR INLET( <br /> PUMP ON AND OFF) ✓ 31 D VES ENO NEAREST j d <br /> SOIL ABSORPTION SYSTEM.Check the sail moisture at the depth of plowing LENGTH DIAMETER MATFRIAL ANDMARKING <br /> or excavation. (If sail can be rolled into a wire,construction shall cease until FORCE / �/7 <br /> the soil is dry enough to Continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> BED/TilWIDTH LENGTH NO OF DISTR PIPE SPACING COVER _ INSIIIE DIA APITS LIOUIO <br /> DIMEN '@N SIONS S Z MAT L'. PIT DEPTH. <br /> DIMEN ' J Tj` / (OAddle� <br /> GRAVEL DEPT FILL DEPTH DISTR PIPE DISTR PIPE OISTR.PIPE MATERIAL NO DISTR NUMBER OF PROPERTY L BW LDING VENT TOFR <br /> BE Low vIPE� ABOVECo R EL � T ELEV END P'PE}t FEET FROM LINE AIR INLET' <br /> (/l� P / <br /> NEAREST "i� `17< r 46 3 <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 PERMANErvr MARKERS. aesER VAnoN wEus <br /> EYES ENO : YES — NO <br /> DEPTH OVER TRENCH:BED DEPTH OVER THENCH:BED DEPTH OF TOPSOIL SODDED SEEPED MULCHED <br /> CENTER EDGES <br /> EYES <br /> ❑NO ❑VES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH No.OF LATERAL SPACINGGRAVEL DEPTH BE LOW PIPE FILL DEPTH ABOVE COVER <br /> BED/TRENCH TRENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE M ANIFOLDMATERIAL. "OOISTH DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELEV.. ELEV. DIA ELEV. PIPES DIA.' <br /> ELEVATION AND <br /> DISTRIBUTION HOLE 512E HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> EYES_ :: ]NO ❑VES EII <br /> COMMENTS: PERM^"E"T M^RKERs- OBSERVATION WELLS'. NUMBER OF PROPERTY II WELL BUILDING'. <br /> FEET PROM LINE <br /> EYES : NO ❑VES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIG TORE TITLE <br /> DILHR SBD 6710(R.01/82) <br />