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DEPARTMENTOF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LA60R&HUMAN RELATIONS DIVISION <br /> P.0.90K 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 state Plan 1 D.Number <br /> CONVENTIONAL ❑ ALTERATIVE of aasig°eat <br /> ❑ HoldingTank ❑ In-Ground Pressure ❑ Mound <br /> NAMEOFPU'1I'.HOLDER ADDRESS OF PERMIT HOLDER INSPECTION DATE'. <br /> a.-89 <br /> B E�NC ,HMA iPerm Trent refe., Poinp D SCRIBE IF D FERENT F OM PLAN'. REF.PT.ELEV.'. CST REF.PT ELEV.: <br /> -1 ✓ill ki �na� — ewa — eoNai PCm.brr.KMP/MPRSW No County. Sanitary Permit Number <br /> 0� r'—C' <br /> PTIC ANK/HOLDING TANK: <br /> M ANUF OBER: LIQUIDCAPAGITV. TANK NLET ELEV. TANK OUTLET ELEVr. WARNING LABEL LOCKING COVER <br /> / (�D 77, {� /'p/.��f PRO IpED. PROVIDED <br /> l / /I / 7Vn a YES ❑NO YES ❑NO <br /> BEDDING. VENTDIA.' VENTMATL.'. HIGH WATER NUMBEROF ROAD'. PROPERTY WELL: BUILDING I VENT TO FRESH <br /> EYES LKNO 1( ( � ALARM ETFROM q LIN �j AIR INLET <br /> __ L NO NEAREST�� f�C� �— <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED. <br /> ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMPAND 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� <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 /> NVENTIONALSYSTEM: <br /> WIDTH LENGTH' NO.OF DISTR.PIPE SPACING'. COVER INSIDE DIA.' }/PITS LIQUID <br /> BE I / TRENCHES'. MA ERIAL'. <br /> DIMENSION 9 , g 5& .�� / `17,�.� PIT DEPTH <br /> GRAVEL DEPT FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> BELOW PIP€5: ABOV;tCOVER I EL v.INLE ELEV.END PIPES. FEET FROM LINE / q' AIR 1 L T. f <br /> J? a7 NEAREST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material forFELEVATIONS <br /> E A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that itERSE SIDE. SHOW <br /> EYES ❑NO meets the criteria for medium sand. MEASURED. <br /> SOIL COVER TEXTURE: =PERMANENT R OBSERVATION WELLS; <br /> ❑YES ❑NO ❑YES—ED 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 /> jDEN <br /> ENCH WIDTH: LENGTH: NO.OF LATERAL SPACING'. GRAVEL DEPTHBELOW PIPE: FILL DEPTH ABOVE COVER: <br /> TRENCHES <br /> IONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING'. <br /> ON AND ELEV.. ELEV.. DIP.'. ELEV.. PIPES. DIAIBU <br /> ATION MOLES12PHOLE SPACING DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIF CCORRESPONDSTO <br /> ATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> NTS: p PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'. <br /> (� lFEET FROM I LINE <br /> ❑ <br /> ❑YES NO 1:1 YES ❑NO NEAREST—♦ , <br /> ^j 19 6 <br /> Sketch System on 101* ^0 _ Retain in county file for audit. <br /> Reverse Side. sIGNArFEE TITL <br /> SBD-6710(R.06/88) <br />