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-.21-S� li 30 - / . LT <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY 8 BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX e969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MPDISON.Wit 53707 Slate Plan LD.Number: <br /> CONVENTIONAL ❑ ALTERATIVE lu a5$1e�eal <br /> El Holding Tank Elin-GroundPressure ❑ Mound <br /> NAME OF PER141?HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE'. <br /> L VA L�ti n �9� Lon K�. 'fin r �l o G- C) <br /> BENCH MARK IPermarentrefer[[n��c��ejjpomt)DESCRIBE IF DIFFERENT FROM PL N: REF PI ELEV.: OST REE .ELEV.'. <br /> ��Tit 'D /r <br /> Named luI 1 MPIMPRSWNo. Goumy: Sanitary Permit Num b r. <br /> r � _ ;�� rn 6e l��oao I y�l15) <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURE 1 LIQUID CAPACITY'. TANK INLET ELEV.: TANKOUTLETELEV.'. WARNING LABEL LOCKING COVER <br /> W IeSQ� /LOO � ry•�� PROVIDED. FROM ILED <br /> . <br /> _ V •7 YES ❑NO B'YEg"�Ii <br /> BEDDING VENT'TI'DENT DIA ✓ENT MAIL. HIGH WATER NUMBERO •ROAD' PROPERTY WELL BUILDING: VENT TO FRESH <br /> „ ALA RM. j E y )) AIRINLET'. <br /> LLJYES NO Cas1- FEAREST� fo�oo p� /� /O,S <br /> DOSINGSING C <br /> MANUFACTURFR. BEDDING. LIQUID CAPACITY: PUMP MODEL'. PUMPISIPHON M ANUFACTURER: WARNINOTABEL LOOKING COVER <br /> PROVIDED: PROVIDED: <br /> ❑YES ❑NO ❑YES ❑NO I [__]YES ❑NO <br /> GALLONS PER CYCLEPUMP AND CONTROLS OPERATIONAL: NUMBEROF PROPERTY WELL. BUILDING'. VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET. <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST—I <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 /> ONVENTIONAL SYSTEM: <br /> WIDTH LENGTH. NO.OF DISTR.PIPE SPACING: COVER INSIDE DIAr. #PITS: LIQUID <br /> BE WIDTH <br /> TRENCHES: / MATER PIT DEPTH <br /> DIMENSIONS ';t ii a &• _ (, lli ma �-- -- <br /> GRAVE I_DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR PIPE MATERIAL: NO.D STR. NUMBER OF PROPERTYJ WELL: BUILDING: VENT TO FRESH <br /> BELO PI ES AB�4V COVER' ELEV.INLET EL EV END: r PIP FEET FROM LIN - I AIR NLET: <br /> 4� y F Ii ON, qL1019 NEAREST-- rv(/ >)010 W, 6• S <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 /> SOILCOVER TEXTURE SENT MARKERS OBSERVATION WELLS: <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENGHBED DEPTHS OF TOPSOIL SODDED. SEEDED- MULCHED'. <br /> CENTER: EDGES. <br /> El YES ❑�NO ❑YES LINO EYES E-1 NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BEDITRENCH WIDTH: LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. <br /> RENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING. <br /> ELEV. ELEV.'. DIAL. ELEVr PIPES. DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE'. HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION I APPROVED PLANS <br /> ❑YES ENO I ❑YES LINO <br /> PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL'. BUILDING. <br /> COMMENTS: 'g III <br /> FEET FROM LINE <br /> %1 ❑YES [-]NO ❑YES ❑NO NEAREST <br /> 7 /� <br /> l A 3�1 8 3.� `Sys�e�r F rF,o� <br /> r P1 ' 9d <br /> y4 ��-� ��I D��r � Ian` " ���� � <br /> S by 3 <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIGNATURE: / TI <br /> SBD-6710(R.06/88) /Vy. <br />