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DEPARTMENT OF INDUSTRY, �NSPECT�ON REP SAFETY 8 BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON ',VI 53707 State Plan I .Number. <br /> XCONVENTIONAL F-1ALTERATIVEPi tuXigoem) <br /> ❑ <br /> Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NA pF IF MIT-HOLD) ) ADDRESS OF PERMIT HOLDER. /�'/C „y f wC INSPECTION GATE <br /> faro � '1 )/_�• n YN' <br /> BENCHMARK(Permanent�terence point)DESCRIBE E DIFFERENT FROM PLA 103 REF,PT. L V.'. GST REF.PT.ELEV.: <br /> Nameo Iii 1 MPIMPRSW No.. SCounty Sanitary Permit Number <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER'. LIQUID CAPACITY: T KI L ELEV. TANK TLE EV.' WARNINGLABEL LOOKING COVER <br /> 0 N PR VIDEO'. <br /> YES ❑NO ❑YES ❑NO <br /> BEDDING VENT IA// VENT MATL.: HIGH WATER NUMBER OF ROAD' / / PR PERT WELL: BUILDING'. VENT TO FRESH <br /> JJALARMj♦® I AIR INLET'._ <br /> ❑YES NO C4sr ❑YES ❑NO NEAREST <br /> �/( / / C/Lj <br /> DOSING CHAMBER: <br /> MANUFACTURER. BEDDING LIQUID CAPAGITV'. PUMP MODEL'. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED'. PROVIDED: <br /> _ ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> GALLONSPER CYCLE'. PUMP AND CONTROLS OPERATIONAL: NUMBEROF PROPERTY WELL'. BUILDING'. VENT TO FRESH <br /> (DIFFERENCE BETWEENFEET FROM LINE: AIR INLET. <br /> PUMP ON AND OFF) LlYES ❑NO NEAREST---► <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 /> he soil is dry enough to continue <br /> CONVENTIONAL SYSTEM: <br /> WIDTH LENGTH- NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA LIQUID <br /> BED/TRENCH TRENCHES: / L MATERIAL- PIT <br /> DIMENSIONS � <br /> GRAVE—DEPTH FILL DEPTH DISTR.PIPE I DISTR,PIPE I DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING'. VENTTOFRESH <br /> BELOW PIS: ABOVE FVER: ELEV.INLET. ELEV.END: S.fm "� 9 PIPES: FEET FROM LINE. / - 11 `� / AIR W ET/ <br /> 7/ pY L]13 NEAREST�� <br /> MOUND SYSTEM: <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 MARKERS'. OBSERVATION WELLS, <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHSOF TOPSOIL SODDED' SEEDED'. MULCHED <br /> CENTER. EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH. LENGTH'. NO.OF ATERALSPAG ING. GRAVEL DEPTH BE OW PIPE: FILL DEPTH ABOVE COVER' <br /> DIMENSIONS TRENCHES' <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAI_. N0.DISTR. DISTR PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING'. <br /> ELEVATION AND ELEV.'. ELEV.'. DIA.: ELEVr. PIPES. DIA.'. <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO [-]YES ❑NO <br /> PERMANENT MARKERS. OBSERVATION WELLS'. NUMBEFRR OF PROPERTY WELL BUILDING. <br /> COMMENTS: FEETOM LINE <br /> j/ ZETYES, ❑NO U YES - NEAREST <br /> Retain in county file for audit. <br /> Sketch System on <br /> Reverse Side. sIGNATUBE. {/ TITLE <br /> SBD-6710 106/88) <br />