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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,W 153707 <br /> ER CONVENTIONAL ❑ALTERNATIVE stat wan LD.Namber: <br /> Rf aseiPnMl <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPEC N DATE: <br /> Mike Stromberg BOX 36, Webster, WI 54893 '02� <br /> BENCHARK(Permanent nfarence point l DESCRIBE IF DIFFERENT FROM PLAN. REF.PT ELEV.: CSTREF.PT.ELEV.'. <br /> Balm s; GQ� gYs ,lfld�x� s,�<< <br /> Name pf Plumber. MPIMPRSW County: Sanitary 5eit Number. <br /> met Burnett 1014.98 (13459 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAPgCITV: TANK INLET ELEV.: TA NK OUTLET ELEV.'. WAflNI COVER <br /> LABEL LOCKING <br /> �� PROVID PROVIDED: <br /> Y SS ONO DYES ONO <br /> BEDDING'. VENTDIA' VENTMATL'. HIGH WATER NUMBER OF RogD: " LRIOE ERTY ELL: aUILOIN` VENTLE FRESH <br /> 'c ALARM. AIR INLET: <br /> OYES O �1 It 6 t. ❑VES ❑NO NEAR Ir �OD -/ �� d <br /> MANUF CHAMBER: e <br /> MANUFA TUBER- BEDDING'. LIQUID CAPACITY. PUMP MODEL'. PUMPISIPHON MANUFACTURER- WARN(MG LABEL ]LOCKING COVER <br /> D Pfl VI ED'. PROV ED'. <br /> C\ <br /> DYES O ES ONO I XYEs ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATI ON'�Wa( a FEETFROMPInNE ERT ELL�/ BUIODI G: VENT TO FRESH <br /> (DIFFERENCE BETWEEN 11 cc ry AIR LET: <br /> PUMP ON AND OFF) ❑VES o at CI' NEAREST � / / <br /> SOIL ABSORPTION SYSTEM.Check thesoil moisture at the depth of plowing LENGTH'. DIAMETER MAT DIAL AND MARKING <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE ) / // <br /> the so I is dry enough to continue.) MAIN l ' 1 �, 5 <br /> NTIONAL SYSTEM: <br /> BED BENCH WIDTH: NO.OF DISTR,PIPE SPACING. COVER INSIDE DIA.. #PITS LIQUID <br /> /p/ / TRENCHES MATER IAL;/H/F/'f( PIT -- C pEPTH: <br /> DI NSIONS /p _ <br /> ELDEPTH FILL DEPTH OISTR.PPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH <br /> BELOW PIPES ABOVECOVER. ELI V.INLET:E LEV.END'. PIPES: FEETFROM LINE'.�y / / AIR INLET: / <br /> [( +Q`f �.� r ' a�a9 3 NEAREST ` O <br /> MOUND SYSTEM: bt <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE 5,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 ME ASURED. <br /> ]YES NO <br /> IL COVER TE%TUBE. PERMANENT MARKERS: OBSERVATION WELLS. <br /> DYES ONO DYES NO <br /> DEPTH OVER TRENCH IBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED: SEEDED. MULCHED'. <br /> CENTER: EDGES. <br /> ❑VES ONO ❑VES NO DYES FIND <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH'. NO.OF LATG.ERAL SPACINGRAVELDEPTH BELOW PIPE FILL DEPTH ABOVE COVER'. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLp MATERIAL. NO.DISTR. DISTfl. IPE DIST IBUTION PIPE MATERIAL&MARKING <br /> . <br /> ELEV.: ELEV.. DIA,: ELEV.: PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION -SIZE POLE SPACING'. DRILLED CORRECTLY' COVER MATERIAL: VER TICAL LIFT CORRESPONDS TO APPROVED <br /> INFORMATION PLANS <br /> DYES ONO ❑YES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> 7// FEET FROM <br /> T'1 �� ❑YES ❑NO ❑VES ❑NO NEAREST <br /> Sep�ic 1� le I --I.og " p <br /> Se��` o �ef yeh� p E �.Ocl <br /> 5 "m <br /> iI/i") ,� w�� S� 0U -a1 <br /> �'6� l <br /> J_ � �� <br /> �j `� tirv.�'SCo �Js�•k6G S�/, <br /> Sketvstem oF' J�,(,G� / Retain in county file for and t <br /> Reverse Side. 1\ f'/�'/r <br /> UV SIGNATURE'. TITL <br /> DILHR SBD 6710(R.01/82) ` <br />