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REPORT ON INSPECTION OF SANITARY PERMIT # 26' ca>) <br /> (1) Name ani Address of Permit Holder Person/Persons at Site (2)Date of Inspection <br /> s} <br /> / � T <br /> Name, rens, icense o. oInstalling Plumber J Time of Inspection <br /> (3)INSTALLATION CONSISTS OF: � <br /> ® Septic Tank [] Seepage Trench -Dosing Chamber <br /> ❑Seepage Pit Seepage Bed ❑ Holding Tank ❑ Fill System <br /> )BENC......RK: (. ermanen re erence in escri e: <br /> Elevation of vertical reference point: — Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: <br /> (6)SEPTIC TANK: Manufacturer: ->/_-, Liquid Capacity: <br /> Tank Inlet Elevation : y', Tank Outlet Elev: -? <br /> # ft to lot or property line:_ -- # ft to well : �- <br /> (7)DOSING TANK: Manufacturer: ✓ # of gallons : ,5 DL' <br /> # of gallon pump set for a cycle f gallons ; total capactiy of distribution <br /> lines f�; gallon; size of pump //�_'0( head; gallon per minute <br /> horsepower brand name of pump and model number -� <br /> Is the warning device installed? EIYES ❑NO Wired? OYES []NO <br /> 8 HOLDING TANK: Manufacturer # of gallons ; <br /> construction depth to the cover ft; If septic tank is <br /> being used are baffles removed? YES ❑ N0; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? ❑ YES ❑NO; Wired? []YES <br /> ❑N0; <br /> Locking device on cover? [--] YES ❑ NO; Diameter of vent and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; <br /> ft to residence; ft to well ; ft to property line; <br /> ft to ordinary high water mark of lake or stream; ft to edge of slopes <br /> greater than seepage pit inlet pipe-elevation ft; bottom of <br /> seepage pit elevation ft. <br /> (10) SEEPAGE BED SIZE: ' "' ft width; ; j'ft length; _� the depth; <br /> 7�/ i.neal feet tile; _.O ft to residence; Ye ft to well ; ft to lot or <br /> property line; 9G ft to ordinary high water mark of lake or stream; ft to edge <br /> of slopes greater than 20% falling away toward lakes, water courses or drainage ditches <br /> Elevation of tank discharge line entering bed / 711 ft <br /> (11) SEEP �M <br /> r seepage trench ft; width ft; <br /> tile depth ft; t to well ; ft to ordinary high water mark of <br /> lake or stream; ge of slopes greater than 20% falling away toward lakes , <br /> water courses or drainage ditches; elevation of tank discharge line entering seepage <br /> trench ft. <br /> (12) Has system been installed in area indicated on EH 115? EYES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES ®NO Floodplain? ❑YES NO <br /> DILHR-SBD-609 N.0 /8 <br /> Signature of Inspector: <br />