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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,W 153707 <br /> VENTIONAL I]ALTERNATIVE sl�aa��9I^�iiD.N�mo=`. <br /> Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. � � RE55 OF PE <br /> T HOLDER. � � INSPECTION DATE. <br /> BENCH MARK PermaCe/nmrelerenee pom110ESCRIBE g IF DIFFERENT FROM PLAN qEf PT E_L/E/V [/9STTRET PT L/(EE LLPV <br /> Nam 1 PlumEer MP/MPHSW No Courcy Sannary Perml Numpar <br /> 33a 75�7�0 /a yo 7) <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER. LIOUID CAPACI TY i4NK INLET ELEV TANK OUTLET ELEV WARNING LABEL LOCKING COVER <br /> /7 PHO IDED PROVIDED <br /> �� �7�7� GJ Jj YES ❑NO YU ES ❑NO <br /> BEDDING. DIA. MATT 1111,11 WATER NUMBS R:DF ROAD. PROPERTY WELL. aUILDING VENT TO FRESH <br /> v� q }- <br /> ALARM FEET FROM LINE r / AIV <br /> [DYES O �/ (; 6/ ❑YES ❑NO NEAREST—t O /70� �5(/ �Q <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LIULIHI LAPAI I IV PIIMPMnDLI PUMP.SIPHON MANV1 AT 11 111111 WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED. <br /> DYES ❑NO ❑VES ONO DYES [-]NO <br /> GALLONS PER CYCLE: POMPANO CONTROLS OPERATIONAL NUMBER OF PHIFFI1Tv WPLL VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM `INE AIR INLET <br /> PUMP ON AND OFF) [DYES 1:1 NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowingI I NOHI IIIAMI TI H j1AIIHR1 AND MARKIN', <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 /> w1orH LENUTH ND OI OI5IH VIPL"A'TO" <br /> COVER INVULn1n xPITs L100 <br /> BEID/TRENCH _ l THE NCIIfs � ( ti jr�� PIT DEPTH. <br /> DIMENSIONS J /L'�- <br /> AV L H FILLDEPTH UI5111 Pll`f fI15TH PIPE DISTR PIPE MATERIAL NO I151H NUMBER OF PHOPE RTv WELL BUILDING VENT TO FRESH <br /> BE LDW PIP�SF '� ABOVE COVEN EIfV INI11 ELEV LND - /� 'IP`f t-`EET FROM : LIN ^ qo qIH I�N'L9ET <br /> 9, l 0. NEAREST— ► i bQ <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 /> meets the criteria for medium sand. TIONS MEASURED. <br /> ❑YES ❑NO <br /> SOIL COVER TEXTURE PI RMAN I N T MAH.I Hs OUSF H VA TION WF LLS <br /> _ <br /> DYES [:]NO EYES LINO <br /> OF NTH OVER THE NCD BED DEPTH DVIR THFN1:11 NF1: I11YII1 f1V IllPS(IIL tiIII111F11 �Ff 11[11 MULCHED <br /> CENTER EDGES <br /> -1 YES ❑NO ❑YES [:]No DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENenT NO OF LA T L HAL SPACING L;H AVE L OF PTO Bu nw PIP: FILL DEPTH ABOVE COVER <br /> BED/TRENCH ". TRENCHES <br /> DIMENSIONS -- <br /> MANIFOLD PUMP MANIrf1D DISTR.PIPE MANIFOLDMATELIAL NO 1115TH UISTH PIPE UISiHIBIIIIDN PIPE MATEHIALb MARKING vl <br /> ELEV. ELEV. DIA ELEV. PIPES UTA <br /> ELEVATION AND <br /> DISTRIBUTION HOLE ROLE SPACINO DRILI F 0 OUH11Ec l lY CDVSR MA T TRIAL VERTICAL u1 T CURRE SPONDS TO APPROVED <br /> INFORMATION PLANS <br /> [!]YES ❑NO DYES ❑NO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS NUMBL'R QF. LI CEERTYF— <br /> T_ <br /> weu 6uaolNc <br /> FEET FROM <br /> �Sr // /� ❑VES ❑NO DYES []NO _IN EAR.S7 <br /> T Z 9'9 <br /> c0r� 'e qqr 3? <br /> D. <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> [ERE TITLE <br /> IG T <br /> DI LHR SBD 6710 (R.01/82) <br />