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DEPARTMENT OF INDUSTRY, <br />LAB61R & HUMAN RELATIONS <br />P.O. BOX 7969 <br />MADISON, WI 53707 <br />OF PERMIT <br />INSPECTION REPORT FOR <br />PRIVATE SEWAGE SYSTEMS <br />CONVENTIONAL E] ALTERNATIVE <br />❑ Holding Tank ❑ In -Ground Pressure ❑ Mound <br />ADDRESS OF PERMIT HOLDER: <br />SAFETY & BUILDING <br />DIVISIOI <br />BUREAU OF PLUMBINI <br />State Plan I.D. Number: <br />Ilt a".gnL1, <br />ECTION DATE <br />BED/TRMVCFF'` <br />WIDTH. <br />/ <br />LENGTH <br />8 CRK rmanent reference Point) DESCRIBE IF DIFFERE FROM PLAN: <br />REF. PT. ELEV.: <br />CST REF. PT. ELEV.: <br />. � - <br />INSIUE DIA. <br />#PITS <br />Name of Plumb <br />MP/MPRs No. <br />County: <br />Sanitary Permit Number: <br />[/ <br />yy1a <br />du/zl� <br />vo 33 i o�8� <br />SEPT TANK/HOLDING TANK: <br />MANUFACTURER. <br />LIQUID CAPACITY. <br />TANK INLET ELEV. <br />TANK OUTLET ELEV.. <br />WARNING LABEL <br />LOCKING COVER <br />n <br />NO, DISTR. <br />PIPES <br />,� <br />� <br />` PR <br />J <br />IDED: <br />PROVIDED. <br />VENT TO FRES <br />ELE V.. <br />-} <br />� <br />YES ONO <br />❑YES ❑NO <br />BE DING: <br />VENT DIA.: <br />VENT MATL. <br />HIGH WATER <br />NUMBER OF <br />ROAD: <br />PR OPERTV <br />WELL: BUILDING- <br />/ <br />l ` <br />1 . ! <br />NEAREST --s <br />ALARM <br />FEET FROM <br />/ <br />LINE..-.. / <br />IVENTTOFRESI <br />AIR INLET. <br />DYES NO <br />INFORMATION <br />GQCd <br />DYES ONO <br />NEAREST <br />`3 <br />� <br />DOSING CHAMBER: <br />MANUFACTURER <br />BEDD ING. <br />LIQUID CAPACITY <br />PUMP MODEL <br />PUMP/SIPHON MANUFACTURER <br />WARNING LABEL <br />LOCKING COVER <br />1:1 YES ONO <br />COMMENTS: <br />PERMANENT MARKERS: <br />OBSERVATION WELLS: <br />NUMBER OF <br />PROVIDED. <br />PROVIDED: <br />BUILDING: <br />❑YES ❑NO <br />FEET FROM <br />❑YES ONO <br />I DYES ONO <br />GALLONS PER CYCLE: <br />CONTROLS OPERATIONAL. <br />NUMBER OF <br />PROPERTY <br />WELL BUILDING. <br />VENT TO FRESI <br />(DIFFERENCE BETWEEN <br />7ND <br />FEET FROM <br />uNE _ <br />' <br />AIR INLET <br />I <br />PUMP ON AND OFF) <br />❑YES ONO <br />NEAREST <br />SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing <br />FORCE <br />LENGTH <br />DIAMETER <br />MATERIAL AND MARKING <br />or excavation. (If soil can be rolled into a wire, construction shall cease until <br />the soil is dry enough to continue.) <br />MAIN <br />r'n1U\/9:IUT1n1UAI QVQTFM- <br />BED/TRMVCFF'` <br />WIDTH. <br />/ <br />LENGTH <br />NO. OF <br />TRENCHES <br />IDIS�PlTRPE SPACING <br />/ <br />COVER <br />MATERyA L' <br />PIT <br />INSIUE DIA. <br />#PITS <br />LIQUID <br />DEPTH. <br />DIMENSIONS <br />l�' <br />[/ <br />DIMENSIONS <br />2!X a <br />GRAVEL DEPTH <br />BELOW PIP S t <br />FILL DEPTH <br />ABOVE COVER ELEV <br />DISTR. PIPE <br />INCL <br />DISTR. PIPE <br />ELEV END,,, <br />DISTR. PIPE MATERIAL. <br />NO, DISTR. <br />PIPES <br />NUMBER OF <br />PROPERTY <br />LINE: / <br />WELL: <br />/ <br />BUILDING: <br />VENT TO FRES <br />ELE V.. <br />119" <br />� <br />�/ <br />_n I� <br />PIPES. <br />FEET FROM <br />��Z 1,57 <br />AIR INLE <br />/ <br />l ` <br />NEAREST --s <br />RO <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 />❑YES ONO meets the criteria for medium sand. TIONS MEASURED. <br />SOIL COVER ITEXTURE IPERMANENT MARKERS JOBSERVATION WELLS <br />❑ Y <br />❑ YES <br />UtPIH UVtH IHENCH'BED DEPTHOVER TRENCH, BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED. <br />CENTER EDGES <br />❑YES NO 1:1 YES NO EYES NO <br />PRESSURIZED DISTRIBUTION SYSTEM: <br />Sketch System on Retain in county file for audit. <br />Reverse Side. <br />SIG TU E. TITLE. <br />DI LHR SBD 6710 (R. 01/82) <br />WIDTH <br />LENGTH <br />OF <br />LATERAL SPACING: <br />GRAVEL DEPTH BELOW PIPE <br />FILL DEPTH ABOVE COVER <br />BED/TRENCH <br />TNO. <br />RENCHES <br />DIMENSIONS <br />MANIFOLD <br />PUMP <br />MANIFOLD <br />DISTR. PIPE <br />MANIFOLD MATERIAL. <br />NO. DISTR.------ <br />DISTR. PIPE <br />DISTRIBUTION PIPE MATERIAL & MARKING. <br />ELE V.. <br />ELEV.. <br />DIA. <br />ELEV. <br />PIPES. <br />DIA.: <br />ELEVATION AND <br />DISTRIBUTION <br />INFORMATION <br />HOLE SIZE <br />HOLE SPACING <br />DRILLED CORRECTLYMATERIAL <br />COVER <br />VERTICAL LIFT CORRESPONDS TO APPROVED <br />PLANS. <br />❑YES ❑ NO <br />1:1 YES ONO <br />COMMENTS: <br />PERMANENT MARKERS: <br />OBSERVATION WELLS: <br />NUMBER OF <br />PROPERTY <br />WELL: <br />BUILDING: <br />FEET FROM <br />LINE. <br />❑YES ❑NO <br />❑YES ❑NO <br />NEAREST <br />Sketch System on Retain in county file for audit. <br />Reverse Side. <br />SIG TU E. TITLE. <br />DI LHR SBD 6710 (R. 01/82) <br />