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VIA - `j � < c �� <br /> DEPART AENT 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 " Stete Alan I.D.Number: <br /> CONVENTIONAL ❑ ALTERATIVE ofassigneel <br /> ❑ Holding Tank El In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: Jy, 1 ,L e /� INSPECTngATE <br /> �0 ( 150$ i V) 5soz`z. 5 /�// 70 <br /> BENCH RK rmanentreferenc oinp ESCR EIF DIFFERENT FROM PLAN: REE PT.ELEV.'.I CST REF.P1.ELEV.: <br /> Sl}mE lao <br /> Name of Plumber MP/MPRSWNoc County: Sanitary Permit Number. <br /> IF�v �n �3z5 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER. LIQUID CAPACITY'. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> b�� �� PROVIDED. PROM OED: ��,,qq <br /> CL nENO ❑YES J^JI NO <br /> BEDDING: VENT DIA' VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY BUILDING'. VENT 11 FRESH <br /> !I ALARM: FEET FROM 1�p� LINE y AIRINLET❑YES NO CQ$ ❑YES NO NEAREST� " f `-/ <br /> DOSING C AMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL PUMPISIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> ❑YES LINO ❑YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONALNUMBER OF PROPERTY WELL'. BUILDING'. VENT TO FRESH <br /> (DIFFERENCE BETWEENFEET FROM LINE: AIR INLET. <br /> PUMP ON AND OFF [-]YES ❑NO NEAREST---41- <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 /> WIDTH: LENGTH' NO.OF DISTR.PIPE SPACING COVER INSIDE DIA.: MPITIS <br /> BED/TRENCH / TRENCHES' / / MATERIAA�L//� PIT PTH'. <br /> DIMENSIONS $ 3 �- V ./YC ` <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERT WELL. BUILDING: VENT TO FRESH <br /> BELO PPIES: ABOVE DOVER: E V.INLET ELEV.END' PIPES: FEET FflOM LINE'. ` T .� / AIR NLEE/ <br /> �� 11 a N . 3a �� ,. NEAREST 0 � ✓� <br /> MOUND SYST M: #64hars <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 I TEXTURE'. PERMANENT MA IS: OBSERVATION WELLS, <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TR ENCHI BEDDEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED. SEEDED: MULCHED. <br /> CENTER. EDGES: ❑yES ❑NO ❑YES LINO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH'. LENGTH: NOOF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER'. <br /> RENCHES: <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 /> DISTRIBUTIONHOLESRE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> PERMANENT MARKERS'. OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. <br /> COMMENTS: FEET FROM LINE: <br /> ❑YES ❑NO ❑YES <br /> .❑]N(,O �j NEAREST—► (,� <br /> G 7AitV_ 'Tnl'T(r1C'- it 710 V pip ,z, <br /> 5e <br /> JC_ 74n OwPW — /' <br /> �U1ed� <br /> me 6 (A ec� on e 0`11"' 8.3D <br /> P0 <br /> S9 31!L <br /> IRetain i It county fi le audit. <br /> Sketch System on <br /> Reverse Side. slcNAruR TITL <br /> SIR D-6710UR.06/88) 56/ <br />