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Io -z© -'�61 I I . <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON.li 53707 State Plan I.D.Number. <br /> ❑ CONVENTIONAL ❑ ALTERATIVE (It assigned) <br /> Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> N A.M^,E�.00F1rryF,MIT H OLD <br /> `ER ADDRESS OF PERMIT HOLDER- \ I INSPECTION DATE <br /> BENCH MARK)Pelma ent reference point)D SCRIBE IF IF ERE 7 FROM PLAN: REF.PL ELEVI GST REE PT.ELEV.'. <br /> 4a <br /> PP.,n r MP/MPHSW No. County'. Sanitary Permit Number: <br /> Nam <br /> I�I � ILl3�l� <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER. LIQUID CAPAPI <br /> TANK INLET ELEV.'. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> C� PROVIDED'. PROVIDED <br /> J �P Q Q YES ❑NO YES ❑NO <br /> REDDING VENT DIAL. VENT MATILHIGH WATER OF ROAD' PROPERTY WELL/ BUILD}ING: VENT�- / ALARM'. OM t uNE f J AIR IN <br /> ❑YES O t YES ❑NO NEAREST !! 7II f <br /> DOSINGCHAMBER: <br /> MANUFACTURERBEDDING. LIOUID CAPACITY. PUMP MODEL: PUMP/SIPHON*LENGTH <br /> WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED'. <br /> YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE'. PUMP AND CONTROLS OPERATIONAL: PROPERTY WELL: BUILDING'. VENT TO FRESH <br /> (DIFFERENCE BETWEEN LINE' AIR INLET: <br /> PUMP ON AND OFF) El YES ❑NO <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCEDIAMETER: MATERIAL AND MARKING'. <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/TRENCH WIDTH: LENGTH: NO OF <br /> DISTR.PIPE SPACING. COVER MATERIAL'. INSIDE DIA.: //PITS'. LIQUID <br /> PIT DEPTH: <br /> DIMENSIONS <br /> GRAVEL DEPTH RLL DEPTH DISTR.PIPE DISTR.PIPE DIBTR.PIPE MATERIAL NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> BELOW PIPES: ABOVECOVER ELEV.INLET. ELEV.ENP. PIPES. FEET FROM LINE AIR INLET: <br /> NEA REST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOIL COVER TEXTURE. PERMANENT MARKERS- OBSERVATION WELLS: <br /> ❑YES ❑NO _ ❑YES ❑NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL. SODDED. SEEDED. MULCHED'. <br /> CENTER- EDGES'. <br /> __❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH'. LENGTH: NO OCHES'. LATERAL SPADING GRAVEL DEPTHDELOW PIPE FILL DEPTH ABOVE COVER <br /> : <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV.' ELEV: DIAL. RILEY. PIPES: DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLESIZE. I-SPACING'. DRILLED CORRECTLY: COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> [-I YES [A NO EYES ENO <br /> PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL'. BUILDING. <br /> COMMENTS: FEET FROM LINE <br /> ❑YES ❑NO ❑YES [--]NO NEAREST <br /> Retain in county file for audit. <br /> Sketch System on TITLE: <br /> Reverse Side. SIG RE <br /> SBD-6710(R.06/88) <br />