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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,WI 53707 <br /> CONVENTIONAL ❑ALTERNATIVE dale P1<1 I O NI.mee/ <br /> ❑ olding Tank ❑ In-Ground Pressure 17 Mound Ill assign)) <br /> NAME OF PERMIT HOLDER. ADDRESS OI/F PERMIIT HOLDER. ;Sy3 C7 INSPECTION DATE: <br /> D r <br /> BENCH MARK Mermanecr Terence Faun)DESCRIBE IF DIFFERENT FROM PLAN AEF,PL ELEV.: CST REF.PT.ELEV. <br /> II— <br /> Name I PlumeeMP/MPRSW No Cnumv Samvey Permn Numoer. <br /> S TIC T NK/HOLDING TANK: <br /> MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER <br /> m ` �" /n P VIDE D'. PROVIDED'. <br /> 4 • �s(' 1pr vY' YES <br /> ❑NO ❑VES ❑NO <br /> BEDDING. V[I{i DI . "ATL. HIGHWAYS NUMBER OF ROAD'. PROPERTY WELL. BUILDING'. VENTTOFRESH <br /> L 'Al ALARM FEET FROM I uNE. i ///, IAIR Iry LET. <br /> ❑YES NO ( N-5� EYES IN. NEAREST U 3 �--` <br /> DOSING CHAMBER: IA'rDOr ,t <br /> MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP/9PHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED. <br /> ❑VES ONO DYES ONO ❑VES ONO <br /> GALLONS PER CYCLE: Pu"P AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING. VENTTO FRESH <br /> MIFFERENCE BETWEEN FEET FROM LINE AIR INLET' <br /> PUMP ON AND OFF) ❑VES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moistureat thedepth 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 /> WIDTH LENGTH No.of DISTR PIPE SPACING COVER IrvsIOE DIA +rens LoUID <br /> BED/Tq ENCH v / THE INCHE MATERIAL'. DEPTH. <br /> DIMENSIONS / J 2 6 I w PIT <br /> GRAVELDEPTH FI LL DEPTH DISTR PIPE DISTR PIPE DISTR.PIPE MATERIAL'. NO DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FR ESN <br /> BELOWPIPES ♦� ABOVE COVER ELEV INLET ELEV EN PIPES LINF. <br /> / r� �1 n I/ FEET FgOM / 7 V AIR INLET / <br /> Co 1 I� /P /� / �l.. 3 NEAREST / 3S <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 /> ❑VES ONO meets the criteria for medium sand. TIONS MEASURED. <br /> SOIL COVER TEXTURE PERMANENT MARIE Is OBSERVATION WELLS <br /> 1:1 YES NO ❑YES NO <br /> DEPTH OVER TRENCH r BED DEPTH OVER TRENCH RED DEPTH OF TOPSOIL EDUCED SEEDED MULCHED <br /> CENTER EDGES <br /> LIVES 1:1 NO DYES ENO 1-1 YES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BEDITRENCH WIDTH LENGTH NO OFTRENCEE. LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER <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 DIA. <br /> ELEVATION AN '. <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TOAPPROVED <br /> PLANS <br /> DYES 1-1 NO OYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL'. BUILDING: <br /> FEET FROM LINE. <br /> .D <br /> QmEs_,�iI DYES El NO ❑YES ❑NO NEAREST <br /> T L G ,rz ,C3 _T �, �ge�d, m adc_ J.e_sfry�-�Q-01 <br /> Ci 4oLl kea.I OAJ-y <br /> �3o3'y <br /> Sketch System on Retain in c my file for audit. <br /> Reverse Side. <br /> sIGNgT A� / TITLE. <br /> DILHR SBD 6710(R.01/82) �' G(/�L -fir ' <br />