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a REPORT ON INSPECTION OF SANITARY PERMIT # <br /> (1 Name, and Address of Permit Holder Person/Persons at Site <br /> (2)Date o f ns pe tion <br /> T <br /> Name ess !cense o. o ns a i ng Plumber Tim JL <br /> of I specti on <br /> 7 <br /> (3)-I-NSTALLATION C NS TS OF: 2#15000"epti c Tank [ ] Seepage Trench E]Dosing Chamber <br /> Oseepage Pit040e0epage Bed e <br /> Holding Tank Fill System- <br /> MBENCH <br /> RK: (-P'ermanent referencePoint-)- escri <br /> i <br /> Elevation of vertical referencepoint:- r Slope at site. <br /> � <br /> (5)MATERIAL AND DEPTH OF SEWER: g,W , <br /> (6)SEPTIC TANK: Manufacturer: )f'l.` �- Liquid Capacity: <br /> q Z.;�� <br /> Tank Inlet Elevation: 1 ''' Tank Outlet E1 ev: <br /> # ft to lot or property line: i # ft to wel 1 1 <br /> MDOSING TANK: Manufacturer: # of9 al lons : <br /> # of gallon pump set for a cycle gallons ; total caP actiy of distribution <br /> lines gallon; size of pump head; gallon per minute <br /> horsepower brand name of pump and model number , <br /> Is the warning device installed? []YES EINO Wi red? aYES NO <br /> ❑ <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 0 NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? ❑ YES ONO; Wi red? [:]YES ONO; <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 /> q p <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 /> 61 <br /> (10) SEEPAGE BED SIZE: F ft width; 0:6' ft length; 3,�(,," tile e • <br /> f 1 i.neal feet ti 1 e; ft to residence• t wel 1 . <br /> ft to lot or <br /> property 1 i ne; 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 Off' `�"w ft. <br /> 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; <br /> the 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 gvStPm hPPn i notal i as in arra i nAi ra+aA nn ru 1191 MvCC M kin <br />