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IC)-t1 - � X I ('T I �c <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7969 BUREAU OF PLUMBING <br /> MADISON,W 153707 <br /> CONVENTIONAL ❑ALTERNATIVE sate Planl D.Number. <br /> of a.aia�eai <br /> ❑Holding Tank 11:1 In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER'. INSPECTION DATE: <br /> W � IE(Jr 131fa6f+ 1 (�. / eL lI � ne L, la bM o iz'- 1 - 8� <br /> BENCH MARK(Permen t reference point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PL ELEV.: <br /> Name of PI mbar: "S' No.: County: Sanitary Permit Number'. <br /> SEPTIC TANK A <br /> MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANKOU LET ELEV.: WARNING LABEL LOCKING COVER <br /> n / i <br /> PROVIDED: PH MID <br /> WIYES ONO DYES —]NO <br /> BEDDING: VENT DIA.'. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH <br /> 7 ALARM. FEET FROM jl a LINE / AIR INLET <br /> ;i � � '. <br /> ❑YES [ONO �✓^ DYES ONO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODELPUMNSIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> EYES ONO I I I ❑YES ONO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING'. VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET: <br /> PUMP ON AND OFF) EYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at thedepth of plowing LENGTH. DIAMETER, MATERIAL AND MARKING. <br /> or excavation. (If 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 /> BED/T4UiAICH WIDTH: LENGTH: ' NO,OF DISTR.PIPESPACING. DOVER INSIDE DIA.'. #PITS. LIQUID <br /> TRE HES: MAT RIAL: PIT DEPTH: <br /> DIMENSIONS <br /> TRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR,PIPE DISTR,PIPE MATERIAL NO.OI NUMBER OF PROPERTY WELL:e; BUILDIyG: VENT TO FRESH <br /> BELOW PIPE ABOVE COV ER: ELEV.I,NLLET:ELEV.END'. PIPES'. NUMBEFEET RONI LINE _ AIR INLET: <br /> J-H'/ .f 7 J �;+� �I -' -3 NEAREST—► <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM <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 /> ❑YES NO <br /> OIL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS. <br /> DYES <br /> ❑NO DYES ONO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED' 5EEDED: MULCHED: <br /> CENTER' EDGES. <br /> DYES ONO ❑YES ONO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH. NO.OF LATERALSPACING. GRAVE L DEPTH BE LOW PIPE: FILL DEPTH ABOVE COVER' <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD pump MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTE DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> . <br /> ELEV.: ELEV.: DIA.: ELEV.. pipES: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY: COVER MATERIAL'. pLANSCAL LIFT CORRESPONDS TO APPROVED <br /> ❑VES ONO i <br /> DYES El NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELIS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> DYES ONO ❑VES ONO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGVTURE TITLE. <br /> DILHR SBD 6710(R.01/82) <br />