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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LAB(-W.& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> ❑CONVENTIONAL ❑ALTERNATIVE Stam TF 1. D,Number: <br /> men l <br /> Holding Tank ❑ In-Ground Pressure 1-1 Mound <br /> NAME OF PERMIT MOLDER. �� qj pRIEBS OF PERM HOLDER. S INSPECTIO D � <br /> njni <br /> BENCH MA K(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN- FIEF.PT EV.: CST REF.PL ELEV. <br /> Na (Plumber. MPIMPRSW No.'. Gauntly Samlary Permit Number'. <br /> Do{1 Da n I - )S 3 �u(n 1 1313 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER. LI` OLPPACITY TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER <br /> frU`/L�YN/ \) P 0 DEO. PR VIDEO <br /> YES ❑NO VES ONO <br /> BEDDING. VENTDIA. VENT MATL. HIGHWATEP NUMBER OF ROAo. r PROPERTY WELL BUILDING VENT TO FRES <br /> ALARM <br /> /� FEET FROM ��ll ,�J LINE 477 <br /> /A <br /> ❑VES NO / \//'Jm VES ❑NO NEAREST (/ I//r -z- � /�J '>�J <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDUING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> PROVIDED PROVIDED'. <br /> ❑YES FIND -1❑YES ❑NO VES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPEH Tv WELL BuumN(f -T-VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE 1418INLET <br /> PUMP ON AND OFF) EYES ❑NO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LIN1;TH DIAMETEI) MATEHIAL AND MAHKINO <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 /> BED/TRENCH WIDTH LENGTH Naonres DISTP PIPE SPACING htgrEelAv. INSIDE DIA =mrs LOUD <br /> DIMENSIONS <br /> PIT DEPTH <br /> GRAVEL DEPTH FILL UFPTH UISTII PIPt UISTH PIPE DISTR PIPE MATERIAL NO DISTH NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH <br /> aELDw PIPES ABOVECOVLH I EV (Nut ELEV END PIPES FEETFROM LINE AIR INLET. <br /> NEAREST ► <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 /> ❑VES NO <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> ❑ <br /> SOIL COVER TExTUHE PEHMANE NT MAHKE ITS D(eseHVA nnN WE us <br /> _ YES NO YES ❑NO <br /> DEPTH OVER TRENCH BEO DEPTH OVER THENCH.BEU HEP TEI DF TQPSDIL 5(IDUED SEEDED MULCHED <br /> CENTEH EUQES <br /> ❑YES ❑NO 1:1 YES ❑NO 1:1 YES 0 N <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH LENGTH NFENCHEs LATERALSPACIN('i tHAVEL OFPTH BELOWPIPF FILL DEPTH ABOVE COVER <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATEHIAL NOD 6TN OISTRPIPE OISTRIBU[ION PIPE MATERIAL &MAHKIN(I <br /> ELEV ELEV. DIA ELEV. PIPES OIA <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION ROLE SIZE HOLE SPACING DRILLED CONRECTLY COVER MATERIAL VERTICAL u1 T CORHFSPONUB TO APPROVED <br /> PLANS <br /> El YES- ONO ❑YES ❑NO <br /> COMMENTS: PERMANENT MARKERS OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING <br /> FEET FROM LINE. <br /> ❑VES 11 NO ❑VES ❑NO NEAREST <br /> Sketch System On Retain in county file for audit. - <br /> Reverse Side. <br /> BIG TUNE LITLE �/J <br /> DI LHR SBD 6710 R.01/82) ) <br />