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- 1 a-g� a <br /> DEPARTMENT OF INDUSTRY, P' � 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,WI 53707 O§ <br /> Ip CONVENTIONAL ❑ALTERNATIVE $ifas"' XIn,Numter'. <br /> (Ii assigned) <br /> ❑Holding Tank ❑In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTIO <br /> Whl '.)C Ile h''-�f I nC vz <br /> BENCH MARK(Permanent. ..ante D nnD DESCRIBE IF D FFEKENT FROM PLAN: REF. .ELEV. CBT R€5.PTELEV. <br /> . '. <br /> Nam! r,PlumEe.: MP/MPRSW No.'. CoumY: nnary Permi.NumEe.'. <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACT RER: EIDCAPACITY ITANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER <br /> P O IDES PROVIDED: <br /> YES ❑NO -8 O- <br /> BEDDING: YiYT DIA.:- VSYT MAT(.: HIGHW ER NUMBER OF ROAD: PROPERTY WELL: i BUILDING VENTLEFRESH <br /> /<. ALARM: FEET FROM '4J/'� L�sL�F�I ? T �� AIR INLET <br /> DYES NO � DYES NO NEAREST 7(�, 7 <br /> DeMM CHAMBER: r✓(� <br /> MANUFACTURER: BEDDING: LI QUID CAPACITY PUMP MODE L'. PUMPISIPHON MANUFACTURER. WARNING LABEL LOCKING COVER <br /> )� IPTG RO IDED: PRO (DED: <br /> ❑YES NO & YES ❑NO YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND U..I HILSOPERAnoNAL NUMBER OF PROPERTY WELI BU DIN VENT TO FRES <br /> FEET FROM LIN AIR INLET: <br /> (DIFFERENCE BETWEEN <br /> PUMP ON AND OFF) ❑YE NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moisture at the depth of plowing LENGTH: DIAMETER. MAT IA A MgRKING' <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE / <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> W�VQQ,T�H' LENG H NO.OF DISTR.PIPE SPPCING'. COVER INSIDE DIA'. #PITS. LIQUID <br /> BED/TRENCH ✓� TRE NCjs: M ER IAL: PIT DEPTH: <br /> DIMENSIONS - / <br /> g1VEL DEPTH L FILL DEPTH DIST .PIPE DISTR.PIPE DISTR.PIPE MATER( �,/ No.DISTR. NUMBER OF PROPERTY WBLIi BUILDING: VENT TO FRESH <br /> BELOW PIPES <br /> a� / ABOVE E.' E V.INLEJ ELEV.EN g ���L �7 '/ PIPES FEET FROM LINE. d�f LV.e� e/ A>�INLET:� <br /> q�. D l�Li NEAREST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slopeTCheckthe texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <br /> and furrows thrown upslope: systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> he criteria for medium sand. TIONS MEASURED. <br /> ❑YES ❑NO <br /> OIL COVER TEXTURE'. PERMANENT MARKERS'. OBSERVATION WELLS. <br /> DYES ❑NO El YES ❑NO <br /> DEPTH OVER THENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL'. SODDED. SEEDED: MULCHED'. <br /> CENTER. EDGES'. <br /> DYES ❑NO ❑VES ❑NO ❑VES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH'. LENGTH'. NO.OFjTERAL SPACING: GRAVEL DEPTH BELOW PIPE'. FILL DEPTH A80VE COVERBED/TRENCH TRENCHESDIMENSIONS <br /> MANIFOLD PUMP MANIFOLDSTRPIPEMNIFOLD MATERIAL NOOISTR. DISTR. IPDISTRIBUTION PIPE MATERIAL&MARKINGELEVELEV.'. DIA.-. EV.: PIPES: DIA.ELEVATION ANDDISTRIBUTION TCLESIZE HOLESPACING: DRILLED CLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> ❑ <br /> Els <br /> —]YES ❑NO <br /> PERMANENT MAR KERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> COMMENTS::, LINE <br /> DYES ONO DYES ❑NO NEARESOM <br /> Mal <br /> � <br /> � <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SI ATUR <br /> DI LHR SBD 6710(R.01/82) �i <br />