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(1) Name and <br />ame, <br />REPORT <br />ON INSPECTION OF SANITARY <br />PERMIT <br /># 901_L) <br />s of Permit <br />Holder Person/Persons at <br />Site <br />1(2)Date of Inspection <br />�l�l,lv <br />me f Inspection <br />3)INSTALLATION CONSISTS OF: 0,5eptic Tank ❑ Seepage Trench [:]Dosing Chamber <br />U Seepage Pit LJ -Seepage Bed LJ Holding Tank U Fill System <br />(4)BENCHMARK:(Permanent reference Point, Describe. <br />Ito* <br />Elevation of vertical reference point: ���_ Slo at site <br />(5)MATERIAL AND DEPTH OF SEWER: •- a- % to <br />(6)SEPTIC TANK: Manufacturer: EQ Liquid Capacity: <br />Tank Inlet Elevation: 9 Tank Outlet Elev: <br /># ft to lot or property line: # ft to well <br />M DOSING TANK: Manufacturer: # of gallons: <br /># m set for ac cle <br />y gallo i�tCys�of distribution <br />lines ga on; head; gallon per minute ; <br />horsepower of pump and modeIs the warni evice installed? �ame <br />YES ❑ NO Wired? ❑ YES ❑ NO <br />8 HOLDING TANK: nufacturer o gallons ; <br />construction ; depth to the cover septic tank is <br />being used are baffles re YES ❑ NO• from rest e; <br />ft from well; ft e. Type of warning device <br />Is the warning device installed? . ed? ❑ YES ❑ NO' <br />Locking device on cover? ❑ NO; Diameter of ve t rival ; <br />Distance from build' vent <br />(9) SEEPAGE Pl,SSIIZE: <br />ft to'Tce <br />ft to ordinary hig <br />greater than <br />seepage pit elevation <br /># of pits; <br />u„ - ! <br />ft to property line; <br />or r ft to edq <br />epage pit inlet pipe-eleva <br />ft. <br />ft liquid depth; <br />0 slopes <br />tom o f <br />(10) S E GE BED SIZE: ft wi dth; glieffft length ti a depth; <br />lineal et ti e; 3�ft to residence; ft to well; ft to lot or <br />property line ft to ordinary high water mark of lake or stream; ft to edge <br />of slopes greater than 20% falling away toward lakes, water courses or drainage ditches <br />Elevation of tank discharge line entering bed ft. <br />Total len <br />tile depth <br />lake or stream; <br />water courses or drain <br />trench ft. <br />­ <br />h of seepage trench ft; width ft; <br />ft to well; ft to ordinary high water mark of <br />ed 'n away toward lakes, <br />levation of �tankdischarge line ring seepage <br />(12) Has system been installed in area indicated on EH 115? <br />❑ NO <br />(13) Has system been installed in floodway? [:]YES 0 Floodplain? [:]YES 0 <br />DILHR-SBD-6095 N.0 /80 <br />Signature of Inspector: <br />