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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 �JI <br /> IgICONVENTIONAL El ALTERNATIVE scare Pla�I o.rvUmaer. <br /> Ill assi4n� <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDE19 ADDRESS OF PERMIT HOLDER INSPECTION DATE <br /> u�, c� 'nt P 3 5 Ar, �5'ii 3 - 2 AFF <br /> B H MARK(PErm anem r Ile 1, m0 DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELFV.. CST REF.PT.EL EV' <br /> Name PIu ber �J MPiMPRSW Nn.. C...lyy Samlary P11-1 Num <br /> SEPTIC TANK <br /> MANUFACTURER LIQUID CAPACITY TANK IAILET ELEV TANK OUTLET ELEV WARNING LABEL LOCKING COVER <br /> PROVIDEDPROVIDED' <br /> Q' VES DN O DY ES ❑NO <br /> BEDDING VENT DIA. VENT MAT,. HIGHWATER NUMBER F ROAD- PROPERyy�� WFE�J�L�;,��� BUILDING VENT TOFRESH <br /> ALARM FEET FROM �- LIr: l /.v/v 1A <br /> DOSING <br /> AIR INLET <br /> DYES NO L ❑VES ❑NO NEAREST <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING IIOUIU CAPACITY PUMP MODEL PUMPISIPHON MANUFACTUmH WARNING LABEL LOCKING COVER <br /> PROV IDED. PROVIDED. <br /> ❑VES 11 NO E:]YES ❑NO OYES [:]NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BOILDIrvG VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. <br /> PUMP ON AND OFF) E]YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowi ng LENGTH DIAME ILL MATEHIAL 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 /> ssnn CC����ppuu WITH LEN GrH No OF DISTR PIPE SPACING COVER INSIDE01- ttPl rs LIQUID <br /> BED/gAwre / /y TREryCHES MATE IAL'. PIT pEPTH. <br /> DIMENSIONS (T1[ / <br /> GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR PIPE DISTR.PIPE MATERIAL. NO DISTR. NUMBER OF PROPERTY "1,,, BUILDING. VENTTO FRESH <br /> BE Low PIPc� // ABc'�EavER ELEIN ELEv.END iI PIP FEET FROM LINE. P,w ' `r AIR INLET. <br /> (!/T or ' NEAREST— W. JL � <br /> MOUND SYSTEM: <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 MEASURED. <br /> OYES FIND <br /> SOILCOVER rE%TUNE PERMANENT MARKER$ III HSERVAT ION WFLLS <br /> El YES Ll NO DYES LINO <br /> DEPTH OVER TRENCH:HED pEPTH OVER TRENCH:PED UFPTH OF TOPSOIL SODDED SFEDEDMULCHED <br /> CENTER EDGES <br /> ❑YES ❑NO ❑VES 101 YES ❑YES NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIOTH LENGTH NO.OF LATERALSPACING GRAVEL DEPTH BELOW PIPE FILL DEPT H ABOVE COVER <br /> BED/TRENCH TRENCHES. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DI SEE PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PI PE MATERIAL&MARKING <br /> ELEV. ELEV. DIA ELEV.' PIPES CIA. <br /> ELEVATION AND <br /> DISTRIBUTION TOLE HOLESPACING DRI LLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS T—APPROVED <br /> INFORMATION PLANS <br /> DYES ENO DYES ❑NO <br /> COMMENTS] PERMANENT MARKERS-. OBSERVATION WELLS'. NUMB ROF <br /> INE ERTV WELL. BUILDING'. <br /> FEET ROM <br /> ❑VES ❑NO ❑VES ❑NO NEAREST <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. TITLE.. <br /> 51 NATURE. <br /> DI LHR SBD 6710 (R.01/82) �j �� <br />