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DEPARTMENT OF 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 �,� State Plan LD.Number: <br /> 'F:J CONVENTIONAL ❑ ALTERATIVE (If assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIONE <br /> — 12 f) �w�tnt' �� <br /> BENCH MARK(PermeAont r Terence point)UEB REE PT.ELEV.'. CST REF.PT.ELEV.: <br /> LZO oh.e- n e k S lc 11 n 4D0 <br /> Name of Plumber MP/MPRSWVNo.: Coun ` Sanitary Permit Number. <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER- / LIQUID CAPACITY: TANK INLET ELEV. TANKOUTLETELEVr. WARNINGLABEL LOCKING CO VER <br /> r� �, 1 DO'^ ' r y/ / q PROVIDED'. PROVIDED'. <br /> 1T` uJ V I&P d YES ❑NO -_7 YES NO <br /> BEDDING: VENT DIA.: VENT MATL HIGH WATER NUMBEROF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH <br /> /' L ALARM: FEET FROM / LINE' J // Z AIR INTET'. <br /> ❑YES 0Jeas ❑YES NO NEAREST EYES 0J �6OV �i <br /> DOSING CHAMBER: <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: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINEAIR INLETI <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: <br /> or excavation. (It soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH' LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: $PITS: LIQUID <br /> BED/TRENCH l / n/ TRENCHES'. M RIAL:, PIT <br /> DIMENSIONS l o f(JT 5 4.W1 <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WE BUILDING: VENT TO FRESH <br /> BELOW PIPES: ABOVE <br /> OVER'. EL .INLET ELEV.E`ND' PIPES: FEET FROM LINE/ r/ / AIR INLET'. / <br /> JYl Gl/P 1 <br /> NEAREST� /C.1�637 <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 /> [DYES [—INOmeets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVER I TEXTURE: PERMANENT MARKERS'. OBSERVATION WELLS'. <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED. MULCHED. <br /> CENTER EDGES'. <br /> ❑YES ❑NO ❑YES LINO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: NOOF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: <br /> TRENCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> : <br /> ELEVATION AND ELEV.'. ELEV.' DIA. ELEV.. PIPES: DIA.'. <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> E]YES ENO ❑YES ENO <br /> PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL'. BUILDING: <br /> COMMENTS: ^ FEET FROM LINE' <br /> 6 ❑YES LINO ❑YES ❑NO NEARES7---- <br /> �let�oh- <br /> 5 gg 1A7. 6 9z1. 7S <br /> ed 1,Wle, Il 417 k4-.- 'f tz�cw�w_ <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIGNATURE: — TITL <br /> SBD-6710(R.06/88) <br />