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co <br /> 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 /> MAbISON,WI 53707 <br /> CONVENTIONAL [--]ALTERNATIVE state Pun I.D.Number'. <br /> Ofassigner) <br /> EllHolding Tank ElIn-GroundPressure ElMound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLD R. INSPECT ION DATE <br /> ZA : no L / <br /> BENCHMARK Permanent referencePintl DESCRIBE IF DIFFERENT FROM PLAN: REF.PT ELEV.: CST REF.PT.ELEV.'. <br /> Cc <br /> Name of Plumber. MPIMPRSW No.: 6oun y: Sanitary ermit Number'. i^ <br /> r <br /> SEPTIC TANK/HOLDRJI <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET E LEV.: WARM LABEL LOCKING COVER <br /> PROVID D: PROVIDED: <br /> Y 'S ONO El YES ONO <br /> BEDDING: VENT DIA.: VENTMATL.'. HIGH WATER NUMBER OF ROAD: PROPERTY FPL . BUILDING: VENT TO FRESH <br /> ALARM. FEET FROM _ urvE- < < ,1 AIN INLET'. <br /> DYES NO L ❑YES ONO NEAREST •�/� �L° <br /> DOSING CHAMBER: vT vT <br /> MANUFACTURER. BEDDING: LIQUID CAPACITYPUMP MODEL: PUMP/SIPHON MANUFACTURER. WARM 4GLABEL LOCKING COVER <br /> PROVII ED: PROVIDED: <br /> OYES ❑NO I I I ❑ ES ONO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY ELL'. BUILDING: VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: <br /> PUMP ON AND OFF) DYES 1:1 NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH'. DIAMETER'. IMATI RIAL 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 /> CONVENTIONAL SYSTEM: <br /> WIDTH. LENGTH. NO OF DISTR.PIPE$PACING'. COVER INSIDE DIA.: #PITS: LIQUID <br /> BED/TRENCH TRENCHES: ] MAT�ER�MLI PIT DEPTH. <br /> DIMENSIONS �,x .<z i,�-L%cG <br /> GRAVELDEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO DISTR, NUMBER OF PROPE TY WELL: BUILDING: V RI TOET ESH <br /> BELOW PIPE ABOVE COV*R: ELEV.INLET ELEV.ENP'. '� _ PIPES LINE « RIR ET <br /> E- .I { ^C` FEET FROM �L ^.c�/i l 5 -/ <br /> NEAREST ► <br /> MOUNDSYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE I DIAGRAM OFSYSTEM <br /> and furrows thrown upslopes mound systems to make certain that it ON REVEF SE SIDE.SHOW ELEVA- <br /> ❑YES 1-1 NO meets the criteria for medium sand. TIONS MEASURED. <br /> OIL COVER ITEXTURE: PERMANENT MARKERS. SSERVATION WELLS. <br /> DYES ONO 1:1 YES ONO <br /> DEPTH OVER TRENCHI EDpEPTH OVER TRENCH/BED pEPTH OF TOPSOIL SODDED: SEEDED'. MULCHED. <br /> CENTER: EDGES: <br /> DYES 1:1 NO DYES EINO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH. TRENCHES: LATERALSPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER'. <br /> DIMENSIONS <br /> MANIFOLD - PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR. 1 DISTRIBUTION PIPE MATERIAL&MARKING'. <br /> ELEV.'. ELEV.: DIA,'. ELEV.: PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE'. HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VER I tCAL LIFT CORRESPONDS TO APPROVED <br /> PLAN <br /> OYES ONO I DYES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> DYES ONO ❑YES ONO NEAREST <br /> Sketch System on Retain in county file for audi . <br /> Reverse Side. <br /> SIGN{/ LE. <br /> DILHR SBD 6710(R.01/82) v/� r '�a� /r�F<-IC- C17 v ! �T< <br />