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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILD,_ <br /> LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> icing <br /> EJONVENTIONAL ❑ALTERNATIVE s18fe Pill,n LD.NBmber: <br /> ❑ Tank In-Ground Pressure ❑Mound <br /> INSPECTI Ilf ufignetl) <br /> NAME PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: OAT ' <br /> BENCH MARK IPermanmt nhrence poinrl DESCRIBE IF DIFF � PT. L STREF.PT. V <br /> Nam f Plumber: MP/M SW o_ ry � <br /> rmit Numbe. <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUf CTUSER'. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNIN LA EL LOCKING COVER <br /> II J� SO E PROVIDED'. <br /> V C0f'f k7(f �Q LJ YE NO OYES ❑NO <br /> BEDDING: Mlaar Dl A.:f NEWT MATL: HIGH WATER NUMBER OF ROAD' / '� LINE ERTY/ W LL. / BUILDIN%: VAEflN NLET RESH <br /> L ff D 1 ALAR _ FEET FROM ` D �j <br /> DYES NO L l YES ❑NO NEAREST �✓ <br /> DOSING CHAMBER: <br /> MANUFACTURER: REDOING: LIDUID CAPACITY PUMP MODEL: %.T!— <br /> SOIL <br /> TURER. WARM G LABEL LOCKING COVER <br /> �0 1 RO ID D: OV IDED:❑YES NO Y S ❑NO ES ❑NO <br /> GALLONS PER CYCLE: PUMP ANDc ROLS OPERATIOER OF PROPERTY WLC. BUILDING' V NTTLINE' / �/ AIR INLET(DIFFERENCE BETWEEN 1�I FROM7PUMP ON AND OFF) lL`IYES ❑ EST—�SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing : DIAMETER: MATE IAL AND MARKINGor excavation. (if soil can be rolled into a wire,construction shall cease until ( IftoSCIthe soil is dry enough to continue.) V j'1 <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH: NO.OF DISTR.PIPE SPACING: COVER / INSIDE DIA.'. #PITS. LIQUID <br /> BED/TRENCH (� r TRENCHES: M I L: PIT DsvTH. <br /> DIMENSIONS D r l! "--- <br /> GRAVELDEPTH IFILL DEPTH DISTR.PIPE DISTR.PIPE DISTR. E MATERIAL'. NO DisTR. NUMBER OF PROPERTY WELL: BUILDIN�j: V NT OFMt, <br /> BELOW PI ES AB ELpVER'. ELEV.IN LET'ELEV END: K I//j PIPFEET LINE ^( AIR IN T (P <br /> /r r Y 1?fw, "? 0' / �V ` � NEARESTO ►7 ire C-/ : J <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <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 /> 1-1 YES El NO <br /> L OVER TE%TURF: PERMANENT MARKERS'. PRIVATION WELLS <br /> OYES F-1 NO ❑YES 1:1 NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED: SEEDED: MULCHED. <br /> CENTER. EDGES. <br /> ❑YES ❑NO ❑YES EINO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH. LENGTH. No.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL EPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUM MANIFOLD DISTR.PIPE MANIFOLD MATERIAL IND.DISTR. DISTR, IE DISTR BUTTON PIPE MATERIAL&MARKING. <br /> ELEV.: ELEV.: DIA,: ELEV.: PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE. HOLE SPACING'. DRILLED COflRECTLY'. LOVER MATERIAL: VER ICAL LIFTCORRESPONDS TO APPROVED <br /> INFORMATION PLAN <br /> YES ❑NO DYES -1 NO <br /> PERMANENT MAR ERS: OBSERVATION WELLS: NUMBER OF PPERTY WELL: BUILDING: <br /> COMMENTSa:� FEET FROM ROLINE: <br /> ❑YES El NO ❑VES 1:1 No NEAREST- <br /> --role <br /> EARESTT <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIG RE: I LE/ <br /> DI LH R SBD 6710 (R.01/82) i°��� <br />