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C <br /> 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 /> MAQISON,WI 53707 <br /> [29 CONVENTIONAL El ALTERNATIVE satePlan lD.numeer: <br /> m aaaronedi <br /> ❑Holding Tank ❑In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> North Country Realty Box 138, Hinckley, MN 55037 <br /> BENCH MARK(Permanent reference peter)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: CST REE PT.ELEV.: <br /> Name of Plumeer. MP/MPRSW No.: County: Sen.,,Permit Number: <br /> Hopkins 03059 Burnett 91316 (13286) <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANKOUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> DYES ❑NO DYES ONO <br /> BEDDING: VENTDIA.: VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL'. BUILDING: VENT TO FRESH <br /> ALARM: FEET FROM LINE: AIR INLET'. <br /> ❑VES ONO OYES ONO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER'. BEDDING'. LIQUID CAPACITY'. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED'. <br /> ❑YES ❑NO ❑YES ONO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL'. BUILDING'. V NTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINe. AIR INLET: <br /> PUMP ON AND OFF) DYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at thedepth Of plowing LENGTH. DIAMETEH MATERIAL AND MARKING. <br /> or excavation. (If 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 /> BED/TRENCH WIDTH: LENGTH: TRENCHES.OF DISTR.PIPE SPACING. MATEJCQVLRIAL PIT INSIDE OIA.: SPITB'. DEPTIH <br /> DIMENSIONS <br /> GRAVELDEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL'. BUILDING: VNTTOFREBH <br /> BELOW PIPES: BOVE COVER: ELEV. NET ELEV.END: PIPES: FEET FROM LINE: AIR INLET'. <br /> NEAREST <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 /> OYES ONO <br /> IL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS'. <br /> DYES ❑NO DYES ONO <br /> DEPTH OVER TRENCH/BED D EPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED: <br /> CENTER EDGES. <br /> EYES ONO I DYES 1:1 No DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH'. NO.OF LATERALSPACING'. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER'. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR. IPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> '. <br /> ELEV.: ELEV.: DIA.: ELEV,'. PIPES'. <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY'. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED <br /> DYES ONO OYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'. <br /> FEET FROM LINE: <br /> DYES ❑NO DYES ONO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE'. TI LF. <br /> DI LHR SBD 6710 (R.01/82) <br />