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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> DIVISION <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS <br /> BUREAU OF PLUMBING <br /> P.O.BOX 7969 <br /> MADISON,W 153707 <br /> ❑CONVENTIONAL ❑ALTERNATIVE IStatePIan LD.Nr,mbar <br /> of a::ry�Ml <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HO DER ADDRESS OF PERMIT HOLDER: J.S.3'�3 INSPECTION DATE. <br /> mal yaasf n J J ` <br /> BENCH MARK P-Adisnerl reference poa,l DESCRIBE IF DIFFERENT FROM PLAN flEF.IT ELEV.'. CST REF <br /> .PT.ELE V <br /> Neme of Plumber t MP/MPRSW Nn Courcy Sanrfary Permu Number. <br /> SEPTIC TANK/ K: <br /> MANUFACTUREggq LIQUID CAPALIT� TANK INLET ELEV.. TANK OUTLET ELEV.. WARMNG LABEL LOCKING COVER <br /> —J, �/ PROVIOEO. T PROVIOEO. <br /> / /' I YES EYES ❑NO <br /> BEDDING. VENT DI� VENT MP TL HIGHWATER NUMBER OF ROAD. PROPERT`f/ WELL. BUILDING. VENTTOFRE5H <br /> ALARM LINE AIR INLET <br /> FEET FR <br /> DYES NO A / G ❑VES ❑NO NEARESTOM <br /> i <br /> DOSING CHAMBER: <br /> MANUFACTURER REDOING LIOVID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PRovmeo- PflovmeD <br /> []YES ❑NO EYES <br /> —]NO [:]YES ENO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTv WELL BUILUINc VENTT FFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET <br /> PUMP ON AND OFF) F71 YES ❑NO NEAREST <br /> SOI L ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENcrH OIAMETER MATERIAL AND MARKING <br /> or excavation. (it 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 /> WIDTH. LENGTH NO.OF DISTR PIPE$PACING COVER tPITS LIQUIDTRENHEs / M��IIALf4LINSIDEDIA <br /> oePTHDIME SIONSGRAVEL OFPTH FILL EPTH IIISTH PIPF DISTR PIPE DISTR.PIPE MATERIAL NO 5 RPROPERTY i BUILDING. VENT TO FRESHAELow PIPEsf /i ABO VE COVER ELE rN/L/Fr ELEV.END/y ') PIPE ' LINE. ( ! AIRI(LEL <br /> ML.1' L-- _S�- <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 /> DYES ❑NO <br /> SOIL COVER TEXPERMANENT MARKETS OBSERVATION WELLS <br /> EYES ❑NO ❑YES ENO <br /> DEPTH OVER TRENCH:GED DEPTH OVER TRENCH:BED DEPTH OF TOPSOIL SODDED SEEDFD MULCHED <br /> CENTER EDr Es <br /> ❑VES ❑NO ❑VES ❑NO ❑VES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER <br /> BED/TRENICH TRENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLUMA TERIAL NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERI AL&MARKING. <br /> ELEV. ELEV. DIA ELEV.' PIPES DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECT LV COVER MATERIAL VERTICAL LIF—CORRESPONDS TO APPROVED <br /> INFORMATION PLANS. <br /> ❑VES ❑NO EYES [:]NO <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS: NUMBER OF PIKE <br /> ROPERTY WELL'. BUILDING. <br /> FEET FROM <br /> ]YES ❑NO ❑VES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE. TITLE <br /> DI LHR SBD 6710 (R.01/82) Qif 'r�� , /E_ <br />