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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,-Nil 53707 <br /> CONVENTIONAL El ALTERNATIVE satePlanlD.Numee.: <br /> m aeeianeei <br /> ❑ o ding Tank ❑ In-Ground Pressure ❑Mound <br /> NAMEOF PERMIT HOLDER: �/ . Ao RESS OF PERMIT HOLDER: INSPECT( DA�_��— �� <br /> Q C Y1AIT <br /> BENCH MARK(Permanent rmero ce Point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.E EV.: CST REE.PT,ELEV.'. <br /> l 1 <br /> z. <br /> Name of P ber. /� MP/MPRSW No,: COum Sanitary Pe mit N.re Or <br /> Axl �. t)oby) urn 1(? <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTUR�n LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING AB LOCKING COVER <br /> —7 ,/ J PROVIDE PROVIDED'. <br /> / -)C �7 ` �� — (- YE ❑NO I DYES ❑NO <br /> BEDDING: VENT DIA,'. VENT ATL HIGH WATER NUMBER OF ROAD: PROPERTY W BUILDING: VENT TO FRESH <br /> ALARM- / LINE'. / AIRINLET. <br /> i- _ FEET FROM ++�� i <br /> ❑VES NO � r`, <br /> DYES ONO NEAREST J ��� Cil i :ff II <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY'. PUMP MODEL: PUMPISIPHON MANUFACTURER: WARNIN LABEL LOCKING COVER <br /> PROVIDE : PROVIDED: <br /> DYES FIND ❑YE ❑NO ❑VES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WE C BUILDING. V NTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET: <br /> PUMP ON AND OFF) ❑VES ❑NO NEAREST <br /> SOI L ABSORPTION SYSTEM.Check the so l moisture at the depth of plowing LENGTH'. DIAMETER, MATER LAND MARKING. <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> MAIN <br /> the sail is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH: NO.OF DISTR PIPE SPACING: COVER INSIDE DIA.'. #PITS'. LIQUID <br /> BED/TRENCH /� 3 l / TReNCHEs: / I MAT RIAL. PIT DEPTH. <br /> DIMENSIONS (r / /c <br /> GRAVEL DEPTH FILL DEPTH DISTR,PIPE p15TR.PIPE DISTR.PIPE MATERIAL: NO,DIT NUMBER OF PROPERTY W LL BUILDING: VENT TO FRESH <br /> BELOW PIPES 'I ABOVE COYER'. ELEV INLET:ELEV.ENO'. �. PIPESFEET FROM LINE i L / AIR INLET: <br /> NEAREST <br /> MOUNDSYSTEM: <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 MEA URED. <br /> DYES ❑NO <br /> OIL COVER ITEXTURE'. PERMANENT MARKERS'. O SEEVATIONWELLB'. <br /> DYES ❑NO DYES ONO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED: SEEDED. MULCHED: <br /> CENTER EDGES: <br /> DYES ONO DYES NO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH. LENGTH'. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE'. FILL OF TH ABOVE COVER. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUM MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTFL DISTR. E OISTRI UTION PIPE MATERIAL&MARKING: <br /> ELEV.'. ELEV.: DIA.: ELEV.'. PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATPLANS:ERIAL'. VERT( AL LIFT CORRESPONDS TO APPROVED <br /> DYES Mn❑ OYES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF ROPERTV WELL: BUILDING: <br /> FEET FROM INE: <br /> ❑YES ❑NO <br /> DYES ONO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> Is <br /> e, TITLE <br /> DILHR SBD 6710(R.01/82) <br />