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ofz- ; 3& <br /> DFPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LAn,OR&HUMAN RELATIONS DIVISION <br /> P.o.sox 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707State Plan I.D.Number'. <br /> CONVENTIONAL ❑ ALTERATIVE Ofasslgned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDEW. ADDRESS OF PERMIT HOLDER: U-) INSPECTION DA E: <br /> ColIkk"-s Ce Lko Rn�C_ sk %93 / �O <br /> BENCH MARK(permanent reference Point)DESCRIBE IF DIFFERENT FROM P AN REE PT.EL .. CST REF.PT.ELEV.'. <br /> s#mE dfs1'1n o <br /> Nart�oI Plum bar MPIMPRSWNoc Ooun Sanitary Permit Number. <br /> n l3zs�er <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER'. LIQUID CAPACITY: TANK INLETEy�_ <br /> TANK UTLETELE .-. WARNING LABEL LOCKINGCOVER <br /> 75� L �� PROVIDED PROVIDED <br /> VS J YES ❑NO EYES KINO <br /> BEDDING: VENT DIA: VENT MATL.: HIGHWATER NUMBEROF ROADPROPERTY I WELL 61111 1 VENTTOFRESH <br /> f' ALARM: FEET FROM ytfy LIN f -.2 <br /> AIR INLET' <br /> [:]YES NO 1 ❑YES NO HE REST > /VV ` a <br /> DOSING CHAMBER: <br /> MANUFACTURER I BEDDING: LIQUIDCAPAC ITY'. PUMPMODEL'. PUMP/SIPHON MANUFACTURER' WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED: <br /> L_]YES ❑NO ❑YES E]NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET. <br /> PUMP ON AND OFF ❑YES ❑NO NEAREST--* <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH'. DIAMETER: 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 /> WIDTHpLENGTH: NO OF DISTR.PIPE SPACING: DOVER INSIDE DIA.'. /I PITS: LIQUID <br /> BED/TRENCHDIMENSIONS /p / �3 / TRENCHES '/ MATERIA // PIT DEPTH <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DISTR. NUM EROF PROPERTY WELL BUILDING: VENT TO FRESH <br /> BELO PIKS. ABOVE COtVER-. ELEV.I T: ELEV. N I PIPES. FEET FROM LINE�p. �� �D AIR INLET'f <br /> ll J/S rAI NEAREST � aO <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. a <br /> KERS: OBSERVATION WELLS', <br /> ❑NO [:]YES ❑NO <br /> DEPTH OVER TR ENCH/BED DEPTH OVER TRENCHIBED DEPTHSOFTOPSOIL'. SODDSEEDED'. MULCHED'. <br /> CENTER'. EDGES: <br /> ❑ EYES ONO <br /> ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: NO OCHES. LATERALSPACING'. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL:I NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING'. <br /> ELEV.: ELEV.: DIA.: ELEV.: PIPES. DA.: <br /> ELEVATION AND <br /> DISTRIBUTIONryOLE SIZE HOLE SPADING: DRILLED CORRECTLY: COVLR MATERIAL VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES LINO <br /> PERMANENT MARKERS OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> COMMENTS: I,3 FEET FROM LINE <br /> ❑YES ❑NO ❑YES ❑NO NEAREST—,, <br /> FIeVawelt tn& TI uYL <br /> `lwhk 17 3 <br /> ,�lld� �fe (fir/fit <br /> iyJ �iaeroVe�' UYh�n 1/ljd' �qh <br /> C t T a kYe 1kiT feseme AC�Yts�uc�i- h <br /> Retain in county file for audit. <br /> Sketch System on I <br /> Reverse Side. p U�.A' sIGNAruRe TYLE. <br /> Ai; <br /> SBD-6710(R.06/88) <br />