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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> LABOR&KUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7969 BUREAU OF PLUMBING <br /> MADISON;WI 53707 <br /> OCONVENTIONAL ❑ALTERNATIVE salassign egnaPlan cl .NumEer: <br /> (n <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME PERMITH L�R: jlE55 pF.FEfl THOLOu _ a , INSPECTION DATE <br /> h l e CI IH/ 5 <br /> BENCH MARK IPermanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV' CBT REF,PT.ELEV: <br /> IMP s <br /> Name�lum0er; MPIMPRBW No.'. IC t SaniIry uPermit Number: <br /> hG , 7 ,Z,{rr <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER; LIQUID CAPACITY. TANK INLET ELEV.; TANK OUTLET ELEV,'. WARNING LABEL LOCKING COVER <br /> PROVIDED'. PROVIDED; <br /> OYES ONO EYES ONO <br /> BEDDING: VENT CIA.: VENT MATL'. HIGH WATER NUMBER OFROAD: PROPERTY WELL: BUILDING; VENTTOfRESH <br /> ALARM_ FEET FROM LINE: y AIR INLET; <br /> EYES FIND EYES ONO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER'. BEDDINGLIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> EYES ❑NO DYES ONO DYES ONO <br /> GALLONS PER CYCLE: PUMPANO CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING I VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: <br /> PUMP ON AND OFF) DYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH. DIAMETER. MATERIAL AND MARKING. <br /> or excavation. Of soil can be rolled into a wire,construction shall cease until FORCE <br /> the soil is dry enough to continue.) MAIN <br /> CONVENTIONAL SYSTEM: <br /> WIDTH'. LENGTH N0.0F DISTR.PIPE SPACING'. COVER INSIDE DIA.. #PITS. LIQUID <br /> BED/T7ifl1@fF- s / / TRE cHEs: a, mar PIT DEPTH: <br /> DIMENSIONS a ;- 0 1 <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO,DISTR, NUMBER OF PROPERTY WELL: BUILDING'. VENT TO FRESH <br /> BELOW PIZ.d ABOVE COVE-. E LEV.INLEF ELEV.ENO'. ✓ PIPES: FEET FROM LIN <br /> e 1 / AIR INLET. <br /> e,L (p�3 1p / NEAREST--► / 34I <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> EYES ONO <br /> OILCOVER TEXTURE. PEflMANENT MARKERS. OBSER VA TION WELLS. <br /> DYES ❑NO OYES ONO <br /> DEPTH OVER TRENCH/BED D EPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED'. SEEDEC: MDITCHED. <br /> CENTER EDGES. <br /> EYES ONO DYES i- ONO OYES ENO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH. NO.OF LATERALSPACING. GRAVEL DEPTH BELOW PIPE: DEPTH ABOVE COVER: <br /> BED/TRENCH TRENCHES; <br /> DIMENSIONS +t <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR, DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> ELEVATION AND . <br /> ELEV.: ELEV.: DIA,: ELEV.. PIPES'. DIA.: <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE'. HOLE SPACING: DRILLED CORRECTLY'. COVER MATERIA L'. PLANS NO LIFT CORRESPONDS TON APPROVED <br /> DYES ONO DYES ❑ O <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM uNE: <br /> DYES END ❑VES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE TITLE <br /> 14-7 <br /> DI LHR SBD 6710 (R.01/82) 1V�7/HZ�7 L -vy <br />