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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O. BOX,7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> 4 CONVENTIONAL ❑ALTERNATIVE 5111,PI10 LD Number <br /> (II KIBnM1 <br /> ElHolding Tank E:1 In-Ground Pressure 1:1 Mound <br /> NAME OF PERMIT OL ADDRESS OF PERMIT HOLDER INSPELTIO�TF J �� <br /> R/05 a D 5��3 C:d <br /> BENCH MARK IPermanem reference pomp DESCRIBE IF DIFFERENT FROM PLAN REF.IT ELEV C. REF PELEV <br /> Ind l 00 • T.160 - <br /> N I PlumNer: � MPIMPRSW N,, Cnumv Sannery Permit Number <br /> 4ry <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAPACITY TANK INLET ELEV TANK CUTLET ELEV WARNING LABEL LOCKING COVER <br /> 7/ ' rc �.F�O vR0 (DED PROVIDED. <br /> J FF[a�, YES [!]NO <br /> BEDDING VEkr oIA. VFMT MAII HIGH wATEH NUMBER OF ROAD. PROPERTY wE/,.L,,� 6uILr��Nc. PENT TO FRESH <br /> AA } ALARM FEET FROM / LINE , /✓� AIR INLET <br /> DYES O �'� rr ry51 ]YES NO NEAREST �� r30 ��� /�'N�� Vr1 <br /> DOSING CHAMBER: <br /> MANUFACTURER BEOOBNG 1101/II1f APA(:IIv V11MI'M111)EL VlIMF"""'IN MANIT A1:TIIII1T WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED. <br /> ❑YES ❑NO I DYES ONO OYES FIND <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OFF RATIONAL NUMBERdOFI PHOPEHTv WILL BUnDINI, VENT TO THESE, <br /> (DIFFERENCE BETWEEN FEET FROM..: LINE AIRINLET <br /> PUMP ON AND OFF) 1:1 YES ❑NO NEAREST-W-i► <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing ,_FORCE. ,ni OIAMIIEH 1ATIRIAI ANDMAHKINI, <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 /> BEDI7RENDH WIDTH <br /> t LENGTH a NIRID11DlsuH Flvl BvnaN< covElH — INs uL oln =PTTs LIQUIDo1Ni��IkpAj PITDEPTH <br /> DIMENSIONS J <br /> flA EL H FILL DEPTH (ASIA PIPE OISiH PIPE OISTR PIPE MATERIAL NO II SII( NUMBER OF PROPERTY WELL BUILDING VENTTOFRESH <br /> BE Low vIPEs 7// <br /> ABOVE <br /> COVER <br /> Elry Irv111 ELEV IrvDvlPl (FEET FROM : LINE <br /> ( IAT 1, aryl 7�#eETi <br /> 1p it S6OVEC _l/ l NEAREST— •'SU E�"'- >>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 TExTURE .IIm1Aw NIMAIIKIHS OBSERV,r HIIr uS <br /> DYES ONO _❑YES ONO <br /> DEPTH OVER THE NCR BED DEPTH'IF H MENU'BE U <br /> MULCHED <br /> CENTER EOGEs U ❑VES <br /> ❑NO OYES ❑NO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> 'WIDTH LENHTH NO.OF LATERALS ACING GRAVEL UEPTHBk If1W PIPJ FILL DEPTH ABOVE COVER <br /> BED/TRfiNCk! -i TRENCHES <br /> Dl(+4SN$IONS <br /> :.MANIFOLO PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL NO D6TH U15TR PIPE OISTHIBVIION PIPE MATERIAL&MARKING <br /> ELEV. ELEV DIA ELEV PlPfti UTA <br /> ELEYgT1¢ON ION AN <br /> INFORMATION <br /> R <br /> ! HOLE SIZE HOLE SFACHHn <br /> ING DHILILOCO E1Y COVER MAIEHIIL VEHTICAL LIFT CORRESPONDS TOAPPROVED <br /> NF V RMn1ATAT1ON PLAYS <br /> DYES [:]NO OYES ❑NO <br /> COMMENTS: PERMANENT MARKERS OBSERVATION WELLS NUMBER OF : PROPERTY WELL SHILLING <br /> FEET FROM LINE <br /> �3M.8`_ - s 6,1 DYES 1:1 NO [:]YES Ll <br /> ❑NO NEAFIR <br /> --/C'lU �1lfKfl Ff�D-�e Tf°'��.{ 7-J be >�.S'TO wP(I <br /> Y5 � � !le .�_.. T,D„el�fr <br /> TL of i3 T gEo �e�� , so I rAi w <br /> o a <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIG T E TITLE <br /> DI LHR SBD 6710 (R.01/82) <br />