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DEPARTMENTAF INDUSTRY. INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX'7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,W 53707 State Plan LD.Number. <br /> CONVENTIONAL ❑ ALTERATIVE In asslg"ear <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME <br /> TOF�^PERMITHDLDER ADDRESS/OF PERMIT HOLDER (T1 I y� INSPEC ION DATE <br /> --J V L L1J_.SG i "I 1 �J – �'-'��r�Y v.�". I`.-I� �/,r� ct �11��) J����� <br /> BENCH MARK[Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN'. REF.P LEY. CST REF.PL ELEV.. <br /> r! 'Ar tr /e a. e6 <br /> Na of Plumb MP/MPRSW No.: Coun�I Sanitary Permit Number / <br /> SEPTIC TANK/HOLDING TANK: - <br /> MANUFACTURER: L1 LIQUID CAPAPFEETFROM <br /> TANK INLET LEY.: TAIIN��111((OUTLET ELEV.: WARNING LABEL LOCKINGCOVER <br /> [ / r o1I Jp6 p`7 / PRO IDEA' PROVIpEp' <br /> 77 // '/f.'' YES ❑NO FSPES�NO <br /> BEDDING. VENT D A' VENT MATL- HIGH WATER ROF ROAD' PROPERTY WELL'. BUILDING. VENT TO FRESH <br /> It L A,LAAIM�-- LIN / AIR INLETEl YES NC Q V EITEJ LJ NO T <br /> DOSING C AMBER: <br /> MANUFACTURER BEDDING: LIQUID CAPACITY: PUMP MODEL PUMPISIPHON MANUFACTURER WARNI LABELLOCKING COVER <br /> PROVIDED: PROVDEG. <br /> ❑YES E-1NO ED YES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBEROF PROPERTY WELL: BUILDING: VENTTO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIN INLET. <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST---Ill <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 /> the soil is dry enough to continue.) <br /> C ENTIONAL SYSTEM: <br /> BED RENCH WIDTH LENGTH NO OF DISTR.PIPESPACING: COVR INSIDE DIA.: $PITS— LIQUID <br /> / // TRENCHES. / MA ,IAL PIT _� DEPTT <br /> ENSIONS ' /�7 R(.4j <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DIST, PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WEL BUILDING: VENT TO FRESH <br /> BELOW PIP S �BJIyEWVER'. E T Q PIP FEET FflOM LME: y / AIR ET <br /> /l s� JO d .017211 <br /> �°Z I NEAREST �OL <br /> MO ND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SfYS7EM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW r <br /> ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOIL COVER I TEXTURE'. PERMANENT MARK ERS. OBSERVATION WELLS, <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCHUBED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL'. SODDED. SEEDEDMULCHED'. <br /> CENTER: EDGES: <br /> DYES ❑NO [AYES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW P IPE FILL DEPTH ABOVE COVER'. <br /> TRENCHES'. <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING'. <br /> ELEVATION AND ELEV.: LEV. DIA. ELEV. PIPES. CIAr. <br /> DISTRIBUTION HOLE SIZE' HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> COMMENTS: <br /> MARKERS OBSERVATION WELLS NUMBER OF PINE ERTY WELL BUILDING <br /> FEET FROM <br /> 0 ❑YES ❑NO [:]YES ❑NO NEAREST <br /> D <br /> P � <br /> Sketch System on R ai in county filet raud it. <br /> Reverse Side. s[cNATu,e. TITLE ,'", <br /> SBD-6710(R.06/88) <br />