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DEPARTMENT OF INDUSTRY, _ 1UPEG'TION 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 /> El CONVENTIONAL ❑ALTERNATIVE SCOPPIaR I L.Numbaky r <br /> UI assigneal <br /> PA <br /> Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOfER ADDRESS OF PERMIT HOLDER' '�+.�//^' INSPECTION DATE. <br /> BENCH MARK(Pe,TAhe,t reference Pri DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.'. CST REF.PT.ELEV. <br /> Name 1 Plumber. f MEIMPRSW N. County Samlary Permit Number. <br /> K/HOLDING TANK: <br /> MAN CTURER <br /> LOGO CAPACITY TANK INLET ELEV. TANK OUTLET ELEV.' WARNING LABEL LOCKING COVER <br /> • �,( I PROVIDED. P,ROVVIDED. <br /> l z7D .� S3 YES ONO 0YES NO <br /> BEDDING VENT CIA I VENT MATL HIGHWAT4R NUMBER OF ROAD. / PROPERTY WELL BUILDING. VENT TO FRESM <br /> ALARM LC.f• FEET FROM LlrvexJ 1T1,� 1 ,(n( r AIRINrLET <br /> ❑YES NO YES ONO NEAREST �(U GU I UV C� t <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING LIDUIDCAPACITV PUMP MODEL PUMF1IF.ON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED. <br /> EYES ONO DYES [:]NO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBEfl OF PRDVFRTr WELL BwLOINc VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LrvE AIR INLET <br /> PUMP ON AND OFF) EYES ❑NO NEAREST)M <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat thedepth ofplowing LENGTH [AMETEK 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 /> WIDTH LENGTH NO OF DISTR PIPE SPACING COVER INSIDE DIA. #PITS LIDUID <br /> DIMEN IONS TRENCHES MATERIAL: FIT DEPTH <br /> DIMENSIONS <br /> GRAVEL DEPTH FILL DEPTH DISTR PIPf DISTR PIPE DISTR.PIPE MATERIAL. NO COSTA. NUMBER OF PROPERTY WELL BUILDING. V NT TO FRESH <br /> BELOWPIPES ABOVE covER ELEV Iry LF( ELEV.END PIPES FEET FROM LINE'. AIR INLET. <br /> NEAREST <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 /> DYES ❑NO <br /> SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS <br /> ❑YES 1:1 NO DYES LINO <br /> DEPTH OVER rRENCH'BED DEPTH ovFH THENCH:BED DEPTH OF TDPSOOL SODDED SEEDED MULCHED <br /> DENTEN EDGES <br /> 1-1 YES [:3 NO 1:1 YES ENO E-1 YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH iDTH LENGTH. TNo OF RENCHES 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 AND <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY <br /> INRv COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS <br /> 11 YES LINO PLANS <br /> ONO <br /> COMMENTS: PERMANENT MARKERS'. OaSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING'. <br /> FEET FROM LINE' <br /> ED YES 1-1 NO 1:1 YES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE. TITLE. <br /> DI LHR SBD 6710(R.01/82) -�� <br />