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REPORT ON INSPECTION OF SANITARY PERMIT # �'� <br /> (1) Name and Address of Permit Holder Person/Persons at Site (2)Date of/Inspection <br /> Nar ss, cense o. o ns a ling Plumber Ti of Inspection <br /> " 3C <br /> � r <br /> (3)INSTALLATION CONSISTS OF: eptic Tank [-] Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit eepa a Bed ❑ Holding Tank [] Fill System <br /> TTTnWMWR.Termanen re erence in escri e: <br /> y' h <br /> Elevation of vertical reference point: 117 Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: <br /> (6)SEPTIC TANK: Manufacturer: Li id Capacity: <br /> Tank Inlet Elevation: ,y 9 Tank Outlet Elev: j <br /> # ft to lot or property line: 2 6 r # ft to well aLu a L� 2ctrx7 <br /> M DOSING TANK: Manufacturer: # of gallons : <br /> # of gallon pump set for a cycle gallons; total capactiy of distribution <br /> lines gallon; size of pump head; gallon per minute <br /> , <br /> horsepower brand name of pump and model number <br /> Is the warning device installed? [:]YES ❑NO Wired? []YES ❑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 [] NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? ❑ YES []NO; Wired? [DYES ❑ NO; <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; -36 ft length; _y�'' tile depth; <br /> /// 1 i.neal feet tile; .2�' ft to residence V u 4/ft—to well ; /$' ft to lot or <br /> property line; 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 ft. <br /> 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; <br /> tile depth ft; ft to well ; ft to ordinary high water mark of <br /> lake or stream; ft to edge 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? ®YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES E]NO Floodplain? [:]YES aNO <br /> DILHR-SBD-6095 N.05/80 <br /> Signature of Inspector: <br />