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S- R- qo 2 ' od <br /> 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 ID.Number. <br /> 1)6 CONVENTIONAL ❑ ALTERATIVE (if assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER' J A SS'O;F PERMITS Y-e— �C INSPECTION D TE <br /> BEN H MARK)Permanent refer,eInce point)f�ESCRI BE IF DIFFERENT FROM PLAN: REF.PT.ELEV... CST REF.PL ELEV.: <br /> 8otf�rn d tSTclr 'e Cerner-- SAii7F- /o <br /> Nameof Plumber: MPIMPRSW No County: Sari Permit Number. <br /> �r n a2sA qc� > <br /> SEP IC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV r. TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED'. <br /> �.+ UYES ❑NO DES XINO <br /> BEDDING'. VENT DIA.'. VENT MATHIGHWATER NUMBER OF ROAD'. PROPERTY WELL: UILDING: VENTTOFRESH <br /> I� /[ ALARM' FEET FROM LINE AIR INLET: <br /> EYES NO T M CisL. EYES NO NEAREST----* > �� -54 <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'. NUMBEROF PROPERTY WELL.. BUILDING'. VENTTO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINEAIR INLET: <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST---111- <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH'. DIAMETER: MATERIAL AND MARKING' <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> BED/TRENCH �WIDTH' LENGTH I NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.' 4 PITS I LIQUID <br /> DIMENSIONS T a q,� ITRENCHES'. i MATERIAL:, /J PIT <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING'. VENT TO FRESH <br /> BELOW lit ABO COVER' E V.INLET' E V.END'. PIPES'. FEET FROM LINE: 1 .{ q IR INLET'. <br /> I) 11 r a NEAREST SD `I/O ,Q. E C <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 /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOILCOVER TEXTURE'. PERMANENT MARKERS-. OBSERVATION WELLS', <br /> ❑YES ❑NO [--]YES ❑NO <br /> DEPTH OVER TRE DEPTH OVER TRENCH/BED DEPTHB OF TOPSOIL SODDED'. SEEDED'. MULCHED' <br /> CENTER: EDGES'. <br /> ❑YES ❑NO [—]YES ❑NO [--I YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: NOOF LATERALSPACING' 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 /> ELEV. ELEV.'. DIA. ELEV. PIPES-. DA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL.. VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> PERMANENT MARKERS: OBSERVATIONELLS <br /> W : NUMBER OF PROPERTY WELL: BUILDING'. <br /> COMMENTS: FEET FROM LINE. <br /> Bm ❑YES ❑NO ❑YES T❑NO NEAREST 3, �+An <br /> Sketch System on R Iain in county file for audit. <br /> Reverse Side. /rye SIGNATURE TITLE' <br /> SBD-6710(R.06/88)Q!/ <br />