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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 /> El CONVENTIONAL El ALTERNATIVE ISmt.Plan Q.Nume.r. <br /> (if row.) <br /> ❑Holding Tank ElIn-GroundPressure 1:3Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA d <br /> 1C1 �r W o�t �' SL�mccGoe ,te[Xlir�� Y 40 <br /> BENCHMARK(Permanent-reference point)DESCRIBE IF DIFFERENT FROM PLAN'. ID eJ, / REF.PT.EL V.: CST REF.PT.ELEV.'. <br /> �Q/� CIL YbcM_ n9r4lp,C� / ) N <br /> Name.11 Smal,Permit Numeer: <br /> Rod kovs (� � U� 9 �GIi�J�� � ��� Lie 1394/5 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK��JJ JLEyTELEV.'. WARNING LABEL LOCKING COVE <br /> T � 50 FOCI` <br /> � L"'it-E PflOV pED PROVIDED: <br /> i l /Y ES ❑NO ❑YES ❑NO <br /> BEDDING: VENTCIA.- VENT MATL: HIGH WATER NUMBER OF IRO PROPERTY W LL / BUILDING'. VENTTOFRESH <br /> (� ALARM. FEET FROMQ / AIR INLET <br /> DYES O DYES [—IN NEAREST JJJJ 1 ((7 <br /> DOSING CH MBER: <br /> MANUFACTURER'. BEDDING: LIQUID CAPACITY. PUMP MODELPUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVED: <br /> DYES ONO ❑VES ❑NO DYES <br /> ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA L: NUMBER OF PROPERTY WELL'. BUILDING'. VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: <br /> PUMP ON AND OFF) ❑YES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing LENGTH: DIAMETER. 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: .� LEN <br /> / NO.OF DISTR PIPE/PAGING: COVER INSIUE DIA.: #PITB: LIQUID <br /> BED/TRENCH /PJ\ I , TRENCHES'. f MATE wu PIT eaer DEPTH'. <br /> DIMENSIONS <br /> RAV LDEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL'. BUILDING: V NT TO FRESH <br /> BELO PIPEDABOVE <br /> BO w COVERa EL LET'.ELE V.E D: PIPE LINE y 1O/ AIR INLET. <br /> -ao 3 d FEET FROM ^J 77 <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 thrownupslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> DYES ONO <br /> IL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS. <br /> ❑VES FIND ❑YES ONO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL. SODDEDSEEDED: MULCHED: <br /> CENTER: EDGES'. <br /> ❑YES ONO El YES 1:1 NO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH: NO.OF LATERALSPACING: GRAVEL DEPTH BELOW PIPE [VERTICAL <br /> L DEPTH ABOVE COVER'. <br /> SEO TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE TRIBUTION PIPE MATERIAL&MARKING: <br /> ELEV.. ELEV.'. DIA.'. ELEV.: PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING DRILLED CORRECTLY. COV ER MATERIAL: LIFT CORRESPONDS TO APPROVED <br /> INFORMATION NS. <br /> OYES ❑NO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: <br /> FEET FROM LINE: <br /> ❑YES ❑NO ❑VES ❑ AREST NO NE /� <br /> �� 5'Y.s�enr E/eral''a� 2`6, 37 <br /> kj- <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> RE: TI <br /> DI LHR SBD 6710(R.01/82) SIGNATU <br />