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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 <br /> MADISON,WI 53707 BUREAU OF PLUMBING <br /> CONVENTIONAL OALTERNATIVE — <br /> ❑Holding Tank ❑ In-Ground Pressure E:1 Mound <br /> LOP PERMIT HOLD E R. ADDRESSOFPE MITHOLDER. INSPECTION DATE <br /> 13 <br /> B NCH MARK IPerma...I reFf—ce pointy DESCRIBE IF DIFFERENT FROM PLAN qEE PT.ELEV.'. CST REF Pi.ELEV. <br /> Nam DI Plumper MP/MPRSW NO, <br /> ^�,,QQ $znl ary Permll Nump¢/ ` <br /> 0305 X�Lu�. 1 7 6 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAPACITY TANK INLET ELEV TANK OUi LEi ELEV WARNING LgBEL LOCKING COV ER <br /> PROVIDED PROVIp ED'. <br /> DYES ONO DYES ❑NO <br /> BEDDING. VENT DIA.' VENT MATT 111611 WnTER NUMBER OF ROAD PROPERTY WELL BUILDING. (VENT TO FRESH <br /> ALARM FEET FROM LINE AIR INLET <br /> OYES [:]NO LIVES ONO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING II OUI01'np1011Y PUMP MUQEI PUMP.SIPHOJ sI ACIUHEII WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED <br /> EYES ❑NO ❑VES ONO ❑VES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER'OF PHDPIRTv weu Bun Dlrv<, VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM'' UNP AID INLET. <br /> PUMP ON AND OFF) ❑VES ONO NE <br /> SOIL ABSORPTION SYSTEM.Check the soil moistureat thedepth of plowing FORCE INl,l'I OIAAlFIEH NATIHIAI ANDMARK_NO <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 /> WIDTH LENGTH / NO Of DISIH PI SPACIN_, COVEH INSIUL Inn =PITS LIQUID <br /> BEDITAiNCi4 1 <br /> rHf <br /> NO <br /> +,In HInL- PIT DEPTH <br /> DIMENSIONS <br /> RA i FILL DEPTH UI5111 PIP! UISTH PIpE DISTR.PIPE MATERIAL NO D[I V ND BER fLF. PROPERTY WELL BUILDING VENTTOFRESH <br /> BFLOW PIPES ABOVE COFyEH ECI�f V/INI11 fLFV INIJ 'p PIPf SPS V LINE / / AIR INLET <br /> CIL ` /!m'r p �T�oi _1 I �� —1 NEAREST Mj. �Q�.lE <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> ❑VES ONO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TEXTURE Pn_MANI NI MARKnls DUSEHVAT ONwFLLS <br /> _ ❑YES [-]NO DYES ONO <br /> DEPTH OV OVER iHf NCI_BEn DEPTIIIIVIH IHENIII Nf 11 III PIII L)I IIIPS_IIL lllllllf 11 IFF UFIO MULCHED <br /> CENTER EDGES <br /> ❑YES. ❑NO DYES ENO ❑YES 0 N <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH tFROTH NO OF LATE RALSING (,HAVEl.IJE IT"HE 10"PIPf FILL DEPTH ABOVE COVER <br /> BED/TRENCH PACTRENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MAN..OLU DISTR PIPE MANIFOLDMATEHIAL NO DISIH DIBTH PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELEVATIONAND ELEV. ELEV CIA ELEV. PIPfs DIA. <br /> DISTRIBUTION <br /> INFORMATION �70LEsIZE HOLEsP—NC, CIn LL LO Cn H HE TFL—Y COVER MATERIAL VEHTCAL LF T CORRESPONDS TO APPROVED <br /> PLANS <br /> [-]YES ONO OYES ONO <br /> COMMENTS: ERMANENT MgRKERs. 095ERVATION WELLS 'NUMBEA.OF PROPEflTV WELL. BUILDING. <br /> FEET FROMI. UNE <br /> ❑YES ❑NO ❑YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> sm ruflE <br /> DILHR SBD 6710 (R.01/82) nrLE <br />