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n <br /> DEPARTMENT OF INDUSTRY, J INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR BI HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O? BOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE SIme Plan LD.Number: <br /> IH maigneal <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER: '� ADORESSOF PERMIT HO DER: INSPECT ON TE: <br /> BENCH MARK IPermanenl reference PPinl)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV. ICSTREF,Pi.ELEV.. <br /> AJI <br /> Name of tuber: MPIMPRSW No.: Coum Sanivey Permit Number. / <br /> tit �I t� ' <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACIT TANK INL TELEV.: NK OUTLET ELEV.. WARNING LA L PROVINGC VER <br /> 5 PROVIDED: PROVIDED: <br /> /? G/ L ❑YES 0 OYES ONO <br /> BEDDING: VENT IA.: VENT L.'. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT LE FREBH <br /> ALARM' FEET FROM LINE: / AIR INLET: <br /> ❑VES ONO DYES ONO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTUR BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMPISIPHON MANUFACTURER'. WARNING LABEL LOCKING COVER <br /> ��'-►y�J� r P%q+IDED'. P�RO-M,J DED: <br /> / // ❑VES NO �U E031IL L4,( LJ YES ❑NO DOVES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLE OPERATIONAL NUMBER OF PROPERTY / WELL: BWLDIN'_ V11"AIR NTO rFRESH <br /> LE <br /> (DIFFERENCE BETWEEN �x/ FEET FROM <br /> LINE yn 5 '1? <br /> PUMP ON AND OFF) &ES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH: DIAMETER. MATERIAL AND MARKING' <br /> FORCE / 11 ^ 5�'1 �� <br /> or excavation. (if soil can be rolled into a wire,construction shall cease until MAIN rl <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH- ' LENGTH: CIN . DISTR.PIPE S�ACING. COVER INSIDE DIA.-. #PITS: LIQUID <br /> O <br /> BED/TRENCH �r�71 TRENCHES: M9Tf IAL, PIT EPTH <br /> DIMENSIONS �V I a//0"dg` <br /> RAVEL DEPTH FILL OEEppTH DISTR.PIPE DIBTR,PIPE -ISTR.P MATERIAL: NO DisTR. NUMBER OF PROPERTY WELL: BUILDIK�G: V NT TO FRESH <br /> BELOW PIPES /F ABOVVECUVER E LEV.I NL ET.E L EV.END. L // PIP FEET FROM LINE. t ll11I AIR INLET. / <br /> $'3O` 7i 7r G'� NEAREST--►��© 6 7 O <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 thrownupslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> DYES ONO <br /> OIL COVER TEXTURE'. PERMANENT MARKERS: OBSERVATION WELLS: <br /> ❑YES POND ❑YES ONO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCHI9ED DEPTH OF TOPSOIL SODDED: SEEDED. MULCHED. <br /> CENTER EDGES. <br /> DYES ❑NO DYES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH'. —No.OF LATERALSPACING'. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES-. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DIS <br /> TR.PIPE MANIFOLDMATERIAL'. NQDISTR. DISTR,PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELE V,'. ELEV.. DIA.'. ELEV.'. PIPR. DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE­SIZEHOLESPACING. DRILLED CORRECTLY: COVER MATERIAL'. VERTICAL LIFT CORRESPONDS TO APPROVED <br /> INFORMATIONPLANS. <br /> ❑YES ❑NO DYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATIONWELLS: NUMBER OF LEP ERTY WELL: BUILDING: <br /> FEET FROM <br /> DYES ONO ❑VES ONO NEAREST <br /> ?4 �'�rv,v SIC. y5' <br />/Well7a—beZ� <br /> 7SD error prs �e CJ L1 17, 3y <br />� llb <br /> T taJls e/er-{-•rs L°or�f/ NrJ7e so j4 , Z /�j � -rrc..� $h...wW.� too <br /> V � <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SI ATU E: TI L� <br /> l <br /> DI LHR SBD 6710(R.01/82) L' P <br />