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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 Ll ALTERNATIVE ISlare <br /> H FIX LD.NumBer <br /> ❑Holding Tank 11In-GroundPressure ❑Mound a.....LII <br /> NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE // <br /> RDH A''_ 501, S*Hz >;cL<:?e l,(,�ehs7er Cti"? ;vd93 9,_ j- j <br /> — <br /> BENCHMARK(Per reference pomp OE$CRIBE IF DIFFERENT FgOM PLAN AEF.PT,ELEV.. CSTREE PT.ELEV. <br /> y� <br /> Name of Plumt,e,. MPi MERSIN Np. Ccmn, S—A,Permit Number'. <br /> )� "S-9 7 C_ _e z <br /> SEPTIC TANK/FIOtIIc_ <br /> MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV.' TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER <br /> /�( .J // / PROVIDED: PROVIDED <br /> / / (/ ♦�~� VP&t_ Z IVES ❑NO OYES ❑NO <br /> BEDDING. VENT DIA. VENT MATL nIOHnMgTER NUMBER OF gOAD'. irk PROPERTY WF,I,��� BUILDING (VENT TO FRESH <br /> 77 .1 LINE. r `/'/✓/v ( / AIR INLET. <br /> ❑YES NO // � ❑VES ❑NO NEARESTM J3 1 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMPISIPHDN MANVFACTIIHEfl WgRNING LABEL LOCKINGCOVER <br /> PROVIDED. PROVIOEO. <br /> DYES ❑NO DYES ❑NO [!]YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING vENT TO FRESH <br /> IN <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIA INLET. <br /> PUMP ON AND OFF) ❑VES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing FORCE LENGTH DIAMETER MATERIAL ANDMARKINQ <br /> or excavation, (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> BED/1 WIDTH LENGTH NO.OF DISTR PIPE SPACING. COVER INSIDE DIq nPITs LIQUID <br /> DIMENSIONS / TRENCHES ` MArE IAS/ r PIT DEPTH. <br /> 7GAVELDEPTH FILLDEPTH DI TH PIP DI STR PIP DISTR.PIPE MATERIAL NO DI$ R NUMBER OF PROPERTY w L}� BUILDING VENT TO FRESN <br /> BELOW PIPES r( ABovE coyER ELEV IN �ELEv.ENOj/ �� PIPE FEET FROM LI[.� / /�'t'" A AIRyN I.,EV <br /> 97! 9'v'7ti NEAREST I/OrO/ <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 /> ❑VES ❑NO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. <br /> ❑YES ❑NO DYES ❑NO <br /> DEPTH OVEH TRENCH B E D DEPTH OVER TRENCH:BED DEPTH OF TOPSOIL SODOEU SEEDED MULCHED <br /> CENTER EDGES <br /> [-]YES ❑NO ❑YES ONO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH TNO OF RENCHES. LATERALSPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DI <br /> STR OI$TR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELEV. ELEV. CIA. ELEV. PIPES DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SRE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> ❑VES ❑NO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS: NUMBER DP„ PROPERTY WELL. BUILDING. <br /> FEET FROM LINE: <br /> ❑YES ❑NO ❑YES LINO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGN TORE TITLE. <br /> V <br /> DILHR SBD 6710 (R.01/82) C- "7_1 <br />