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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR BE HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7963 BUREAU OF PLUMBING <br /> MADisoN,WI 53707 <br /> ❑CONVENTIONAL ❑ALTERNATIVE Slate Plan LD.Number'. <br /> (lf aacigneal <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAM!OF PERMIT HOLDER: \ADaDRESS OF PERMIT HOLDER: INSPECT( NO TE: <br /> v Yv B <br /> BENCHMARK(Permanent reference point DESCRIBE IF DIFFERENT FROM PLAN: REF.PT. LEV. I CST REF.PT.ELEV.'. <br /> J CA0L /dN O �(7/L <br /> ( eaJ <br /> Name of lumber: MP/MPRSW Na'. Cou Sanitary Pe mlt Number: <br /> 10 )33q <br /> SEPTIC TA K/HOLDING TANK: <br /> MANUFACTURERLIOUI'D�CAP ITTTTTT���... TANK INLET ELEV.'. TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER <br /> / l / ' PPpVJDE PROVIDED <br /> YES-NO ❑YES '{�NO <br /> BEDDING'. DIA.: TMATL HIGH WATER NUMBER OF ROAD: / PROPERTY W L BUILDING VENTTOFRESH <br /> ALARM: FEET FROM urvE- qIR INLE <br /> ❑YES NO EYES �NO NEAREST L/0 V�rU� 1 P 1 <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING. LIOUI D CAPACITY- PUMP MODEL'. PUMP/SIPHON MANUFACTURER: WARNIN LABEL LOCKING COVER <br /> PROVIDED: PROVIDED. <br /> ❑VES ❑NO DYES ❑NO DYES ONO <br /> GALLONS PER CYCLE: PUMP AND CDN I HOLS OPEHA I rmAL: NUMBER OFPROPERTv . VENT INLET <br /> FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE. AIR IN10 <br /> w Lc. BUILDING' <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH'. DIAMETER MATERAL AND MARKING <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE <br /> MAIN <br /> the soil is dry enough to Continue.) <br /> CONVENTIONAL SYSTEM: <br /> WIOT r LENGTH: I NO.OF OISTfl.PIPE SPACING'. COVER INSIDE DIA.'. #PIT$: LIDUID <br /> BED/TRENCH ^ L/ TR ENcH Es. / MATERIgL: PIT DEPTH: <br /> DIMENSIONS <br /> RAVELDEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MgTE wL: No.DISTR. NUMBER OF PROPERTY WELL. BUILDING'. VENT TO FRESH <br /> BELIZE,,—7- ABOy'FCOVE/R ELEV.INLET.ELEV.END' // �) PIP�E^S1 FEET FROM LINE- / Y-J/I { Aw IN E '.* <br /> a-�i fS, // J NEAREST > � 2D e` (p as �� <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDEA DIAGRAMOFSYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVER E SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> 1:1 YES ❑NO <br /> OIL COVER TEXTURE PERMANENT MARKER& SERVATION WELLS. <br /> OYES LINO DYES ❑NO <br /> DEPTH OVER TRENCH/BFO DEPTH OVER TRENCH!BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED'. <br /> CENTER'. EDGES. <br /> DYES ENO DYES DNO DYES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH: LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTR( UTION PIPE MATERIgL&MARKING'. <br /> ELEV.: ELEV.. DIA.'. ELEV.: PIPES: DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLESIZE. HOLESPACING. DRILLED CORRECTLY'. COVER MATERIAL. VERT( AL LIFT CORRESPONDSTO APPROVED <br /> INFORMATION PLAN <br /> DYES ONO DYES ❑NO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'. <br /> FEET FROM LINE: <br /> DYES ❑NO ❑VES ❑NO NEAREST <br /> S �•3 q1("'9 13 T ,?� <br /> LG.G9G0� <br /> Cs� <br /> 13ewcPAR k- — <br /> �D� C�f� T . blRv] <br /> Desf�o�ed a.s 7,e 4.1.5 <br /> IItEletode4 <br /> Sketc System on Retain in county file for audit <br /> Reverse Side. TITLE <br /> SIGN U : / <br /> DILHR SBD 67101R.01/62) �� <br />