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DEPARTMENYOF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 Sate Plan LD.Number <br /> CONVENTIONAL ❑ ALTERATIVE of assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAA/M�/���EOFPEPMITHOLDER' J ADDRESS OF PERMIT HOLDER O L / I , � / C(/yam INSPECTION DAT��_�� <br /> I l � J �t'UC.0 6 <br /> BENCH MARK iPermamem reference point)DESCRIBE IF DIFFERENT FROM PLAN: REE PT ELEV.: CST REE PT ELEV.. <br /> 0 �!6 f"i <br /> Name Flu,I MP/MPRSWNo.' County: Sanitary Permit Number. <br /> �_�'r r )C7,3, ID) 1q3 k <br /> I <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTUR LIQUID CAPACITY'. TANK I LET V TANK OUTLETS EV.: WARNING LABEL LOC KING COV ER <br /> }yyQ G�p' PR VIDED'. PROVIDED: <br /> c- 50 r0A [ 0 �� YES 0 N EYES VNO <br /> BEDDING. VENT DIAVENT MATL: HIGHWATER NUMBER OF ROAD'. / PROP TY WELL'. BUILDING. VENTT ESH <br /> II ALARM' FEET FROM )/ / AIR INLET. <br /> ❑YES NO ❑YES ❑NO NEAREST�� ✓✓ r` /r 3 <br /> DOSING AMBER: <br /> MANUFACTURER- BEDDING: LIQUID CAPACITY'. PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED. <br /> ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM .INE. AIR INLET. <br /> PUMP ON AND OFF ❑YES ❑NO NEAI <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER'. MATERIAL AND MARKING'. <br /> or excavation. (if soil can be rolled into a wire,construction Shall cease Until MAIN <br /> ��ww the soil is dry enough to continue.) <br /> 0114VENTIONALSYSTEM: <br /> /TRENCH WIDTH: / LENGTH' NO OF DISTR.PIPE SPACIG. COVER INSIDE DIA.: /j PITS'. LIQUID <br /> {,., TRENCHES. / MATER fir' PIT �� DEPT. <br /> IMENSIONS / l �� MJ44 TI} <br /> GRAVEL DEPTH FILL PTH DIS R.PIPE DISTR PIPE DISTR.PIPE MATERIAL'. NO.DISTR. NU BER OF PROPERTY WELL. BUILDING'. VENT TO FRES <br /> BELOW PIPES'. 0 OVER ELEV.INLCEJ_. EL rE/ PIPES'. FEET FROM LINE'. 0 / A INLET'. <br /> /) B , 317 7-1,511 /.Jh' Jrla� NEAREST—� I'T <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVEfl I TEXTURE'. PERMAN ENT MARKERS. OBSERVATION WELLS. <br /> ❑YES ElNO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED _ OEPTHSOFTOPSOIL SOODED'. SEEDED. MULCHED'. <br /> CENTER'. EDGES: <br /> ❑YES LINO [--I YES ENI ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER <br /> DIMENSIONS TRENCHES' <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING'. <br /> ELEVATION AND ELEVr , ELEVc DIA. ELEV. PIPES. DIA.- <br /> DISTRIBUTION HOLE SIZE'. HOLE SPACING'. DRILLED CORRECTLY: COVER MATERIAL'. VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING'. <br /> COMMENTS: FEET FROM LINE'. <br /> t16 ❑YES [ANO ❑YES ❑NO NEAREST—► <br /> Ios- <br /> Retain in county file for audit. <br /> Sketch System onIf <br /> Reverse Side. FS— (� ITLE <br /> SBD-6710(R.06/88) 'Y L <br />