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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 /> 9-2i <br /> Name, Address, License No. ot Instaling Plumber Time of Inspection <br /> 3 0 0 <br /> (3)INSTALLATION CONSISTS OF: ® Septic Tank ❑ Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit ® Seepage Bed ❑ Holding Tank _ ❑Fill System <br /> l4)BENCHMARK: (Permanent reference in escri e : � 41— <br /> Elevation <br /> 7-t , <br /> Elevation of vertical reference point: Slope at site: <br /> : <br /> (5)MATERIAL AND DEPTH OF SEWER:A �y��J <br /> (6)SEPTIC TANK: Manufacturer: 1i/ X ;C. Liculid Capacity: 7✓� <br /> Tank Inlet Elevation: 2,4111 Tank Outlet Elev: <br /> # ft to lot or property line: , Z/d/ # ft to well : - <br /> (7)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 /> horsepower brand name of pump and model number _ <br /> Is the warning device installed? [-]YES ❑NO Wired? DYES ❑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? 0 YES ❑ NO; ft from residence; <br /> ft from well ; ft from property line. Type of warning device <br /> Is the warning device installed? ❑ YES [3N 0; Wired? ❑YES []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: 1Z f% width; ,2 ! ft length; � the depth; ,41 <br /> �li.neal feet tile; �f-ft to residence;'qft to well ;,Z,fye 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 /> 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 system been installed in area indicated on EH 115? ®YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES 2]NO Floodplain? []YES ,® NO <br /> DILHR-SBD-609 N.0 /80 - - <br /> Signature of Inspector: ,�� <br />