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p- /0- --/oq6i__0 <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 State Plan I.D.Number: <br /> CONVENTIONAL ❑ ALTERATIVE (u assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PEN MIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. <br /> �n✓a (J r ��a nc �/ 1TJn� SCC ! 6 -/u - 9d <br /> BENCH MARK(Permaent reference point)DESCRIBE IF DIF ERE F OM PLAM / REF.PL ELEV. GST REF.PT.ELEV. <br /> n <br /> Name of umber. MP/MPRSWNo. Co Ft Sanitary Permit Number <br /> - 3 r�ru � l40 15x8 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUF TURER: LIQUIDOAPACITV: TANK INLET ELEV.'. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER <br /> nr� _ P O IDED: PROVIDED'. <br /> _ Q fti 10 U OC]0 YES ❑NO ❑YES 1� In <br /> BEDDING'. VENT DIA. VENT MATL.. HIGHWATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH <br /> L (( ALARM: FEET FROM (/ LINE: pw, �' AIR INLET <br /> El YES NO 7/ LEAS f ❑YES ❑NO NEAREST---* /L8 Y!o{ <br /> DOSING &AMBER: <br /> ANUFACTURER: BEDDING'. LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> p __12 <br /> •� / PRO IDED: PR VIDED: <br /> Ult? or '� <br /> El NO S � liQ�( tc'/ YES ❑NO 7YES ❑NO <br /> GALLONS PER CYCLE. PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELJBUILDING: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' ,(i ./ ACJ AIR INLY, i <br /> PU MP ON AND OFF ❑YES NO NEAREST—► –�v r f;,,-a, If=.+✓ 7" 5 <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 I II /?VL / /,� <br /> the soil is dry enough to continue.) �" V .$L 7 <br /> CONVENTIONAL SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING'. COVER INSIDE DIA/. $PITS: LIQUID <br /> TRENCHES'. <br /> DIMENSIONS , J /^ / PI7 v :-.._.. .._ <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL' NO.DISTR. NNUMBEfl OF PROPERTY WELL'. BUILDING. VENT TO FRESH <br /> BELOW,IPJ= + ABOV/COOVER: ELEv.I�ET. BEV.EN' X� PIPES: FEET FROM LINE. `,/J AIR INLET f <br /> 8 -73, NEAREST O <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'. PERMANENT MARKERS. OBSERVATION WELLS; <br /> ❑YES ❑NO EYES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED: SEEDED-. MULCHED'. <br /> CENTER: EDGES: <br /> ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: Ni LATERAL SPACING: GRAVtBELOWPIPE'. FILL DEPTH ABOVE COVER. <br /> TRENCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL B MARKNGELEVATION AND ELEV.' ELEV.: DIA.'. ELEV.. DIADISTRIBUTION HOLESIZEHOLESPACING DRILLED CORRECTLY'. VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVEDPLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS' OBSERVATION NUMBER OF PROPERTY WELL BUILDING <br /> FEET FROM LINE <br /> ❑YES ❑NO ❑YENEAREST—♦ '\ <br /> pump. 47`9 <br /> yY q 3, b"y <br /> Sketch System on <br /> Retain in county file for audit. <br /> Reverse Side. SIGgr T E rlrL <br /> SBD-6710(R.06/88) <br /> 9 <br /> L. <br />