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(,I & `SSS t), 0A <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 /> MADISON,WI 53707 <br /> ,CONVENTIONAL ❑ALTERNATIVE stele Plan l o.NomBer'. <br /> Ilf BaaiPneel <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. ADDRES5 OF PERMIT HOLDER'. INSPECTI N DATE: 01 <br /> Ern A _TE - �5 v�J��t�m �, ti�:�,l —�1 : 7//-5/ <br /> ENCH MARK(Permanent relerence RomU DESCRIBE IF OI F FE RE T F,R,,,yy,M, PLAN .� /I REE PT. LEV.'. C REE PT.ELEV.: <br /> ocuer l¢ /✓�corNa �'� j7TP ��l/C/ <br /> of Plumber: MP/MPRSW No.: Courcy- Samum,P Imurt Number. <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER'. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.'. WARNIN LABEL LOCKING COVER <br /> / PRO IDE PROVIDED/�/�, <br /> �l �S ��jd Y ONO ❑YES SJNO <br /> BEDDING: VENT DIA.'. VENT MATL,- HIGH WATER NUMBE GF ROAD: PROPERTY W LL: BUILDING'. VENTTO FRESH <br /> A <br /> ALARM /(V FEET FROM �7 LI"E: l ^7 AIR I^ " <br /> LE <br /> OYES O <br /> ❑YES NEAREST G/ ' a oC-, <br /> DOSING CHAMBER: <br /> MANUFACTURE - --/ BEDDING'. LIOUIOCAPACITY: PUMP MODEL. PUMPISIPHON MANUFACTURER: WARN( GLABEL LOCKING COVER <br /> PROVIDEDPROVIDED: <br /> OYES O D &YES ONO YES FIND <br /> GALLONS PER CYCLE: PLjMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY W LL: BUI DIN : VENT TO FR H <br /> (DIFFERENCE BETWEEN FEET FROM LINE.•/► '��f ' 01 AI I <br /> PUMP ON AND OFF) OYES ❑NO NEAREST o p{V <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH: DIAMETER'. MATE IALANDMARKING. <br /> FORCE <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until S <br /> the soil is dry enough to continue.) MAIN oa <br /> CONVENTIONAL SYSTEM: <br /> WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING'. COVER INSIUE DIA. #PITS: LIQUID <br /> BED/TRENCH IF TRE cH MATVIAL PIT <br /> DIMENSIONS Q <br /> GRAVEL DEPTH FILL PTH DIS .PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO DISTR. NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH <br /> BELOW PIPE BOVF�ICOVER ELEV.INLEL EL .ENO'. ,f,y q PIF§ FEET LINE AIR INLET: <br /> 1 ^�,J .7 NEARESTO �_ W JW7 B� <br /> MOUND SYSTEM: �I <br /> t 71 <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 FIND <br /> IL COVER TEXTURE. PERMANENT MARKERS OBSERVATION WELLS. <br /> OYES ONO DYES FIND <br /> DEPTH OV ER TRENCHIBED DEPTH OVER TRENCHIBED DEPTH OF TOPSOIL. SODDED: SEEDED: MULCHED: <br /> CENTER EDGES'. <br /> DYES ONO DYES NO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH. NO.OF LATERAL SPACING'. GRAVEL DEPTH BELOW PIPE'. FILL EPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL: NQDISTR. DISTR.PIPE DISTR BUTION PIPE MATERIAL&M RKING'. <br /> ELEV.: ELEV.: DIA,'. ELEV.: PIPES'. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION NOLE SIZE HOLE SPACING: DRILLED CORRECTLY'. COVER MATERIAL PVERY LAN CAL LIFT CORRESPONDS TO APPROVED <br /> ❑YES NO EYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> Wh_ jj /Qy- a OYES ONO ❑YES ❑N( NEAREST <br /> Zr�eu- <br /> � Lef <br /> �. 7a <br /> DcQm course a>L Ivy Gtrncl-I�u <br /> 0 T-T I C..Si,k4-- 6.x.8 <br /> cr e� <br /> & 19 Kjl 11�"l 6 qud <br /> a <br /> Sketch System on Retain in county file for audi . <br /> Reverse Side. of 19 <br /> SIGNATURE TI LE <br /> DILHR SBD 6710(R.01/82) <br />