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/a 30 <br /> Wisconsin Department Of Industry, ON SITE SEWAGE SYSTEM Safety& Buildings Division <br /> Labor and Human Relations INSPECTION REP RT <br /> P.O. Box 7969 <br /> Madison,Wl 53707 County: <br /> ONVENTIONAL ❑AT-GRADE ❑IN-GROUND PRESSURE []MOUND❑ XPERIMENTAL El NEW ❑REPLACEMENT ❑HOLDING TANK <br /> /,(gI/CE <br /> ❑RECONNECTION ❑OTHER(SPECIFY) <br /> Permit Hold, Name Perm i Holder's Address: 275 Inspection Date' <br /> �i IeS <br /> Bench Mark,Des <br /> cri UP Di Brent From Plan: Parcel Tax LD.No.(Optional) Ref.Pt.Elev.: CST Re Pt.Elev_: <br /> P umber's me: MP/MPRSW No.: State Plan ID No.(1 Assigned): SanitaaPermit Number: <br /> 3 <br /> SEPTIC TANK/HOL NG TANK: ave <br /> Manu acturer: 1 Co'^ Liquid Capacity: Tank nlet Elev.: Tank Outlet Elev_: Warningg Label Lock ing Cover <br /> �iCSet �ncre�e �p0o �— Pr vicled: Provided: <br /> py,Yes ❑ No ❑ Yes No <br /> Bedding: Vent Di Vent Mat 1. H igh Water Alarm: NUMBEROF Road: rt Pro eLine: Well: building: <br /> �r P /Y uilin Air Ve <br /> O meg: <br /> El Yes NO FEET FROM yQ �YeS ❑ No NEAREST Tv �7 / O <br /> DOSING CHAMBER: <br /> MIIan11u aRurec Be ing: Liqui rCapacity: Pump Mo e : Pumpdip on Manu acturer: High WaterA arm Warning Lae Loc ing Cover <br /> Joo 4- �0 e, ',er Provided: Provided: <br /> ❑ Yes No Yes ❑No Yes ❑No Yes ❑No <br /> Gallons Per Cyt e: Pump an Contro s Operationa : NUMBER Property L Wel : Bui inq: Air Vent: <br /> (difference betty) FEET FROM yd-s a'7 �3 l �ir vent' <br /> um on and off) Yes No NEAREST--► <br /> Vent lnsta e : Vent Diameter: Vent Ma rla : FORCE Lengt Di�alm Bier: M�a�t�e)ria an Mar ing: VolENT El Yes No ��' - w'- ^ I 9 j1 R3Pn 9/fig �. 7 / <br /> MAIN <br /> SOIL ABSORPTIONS STEM. Check the soil moisture at the depth of plowing or excavation. (If soil canoe rolled into a wire,construction shall cease until <br /> the soil is dry enough to continue.) <br /> DISTRIBUTION STSTEM: <br /> BED/TRENCH Width: Length: No.Trenches: Lateral Spacing: Coll, r Material: Inside Dia: No.Pits: Liquid Depth: <br /> DIMENSIONS /ai 1/0— I/{.-�- /v„ PIT V` 9:1 <br /> Gravel�Blow Pipe Fill Above Pipe: Inlet Elev.: En Elev-: peMaterial NO.Distr.Pipes: NUMBER OF PropertLine: Well:v Building: Air Vent: <br /> iN7rt 1g ` <br /> [0•/0 e1q o2 NEARES--� / 502 le�4R 17 J <br /> ELEVATION AND Mani old Elev.: Mani old Dia, Mani old Material: No.Distr.Pipes: Distr.Pipe is-: <br /> DISTRIBUTION <br /> INFORMATION Hole Size: Hole Spacing: Drilled Correctly: Permanent Markers Observation Wells: Pump Elev_: Vertical Li tCorresponds To <br /> E] Y., ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ApprO Yes la❑ No <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicularto 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 /> OIL OVER Texture: ETopsow <br /> anent Markers: Observation wells: <br /> ❑ Yes ❑ No ❑ Yes ❑ No <br /> Dept Over Trenc Be Center: Dept Over Trenc Be E ges: EDept..sO. Soauem, See e : Muc e <br /> ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS:(Sketch System On Reverse Side) <br /> 70 43 <br /> _ja5tfiefs y.9E Df 5.9d ' j�3 q 69 <br /> Id.68 %92'31/ �Sysf,� r1e//aAW <br /> Signature' Title: ) <br /> SBD-6710(R.09/90) (Keep ac py in your file for audit) <br />