Laserfiche WebLink
DEPARTMENT OF INDUSTRY, <br />LABOR & HUMAN RELATIONS <br />P.O. BOX 7969 <br />MADISON. WI 53707 <br />INSPECTION REPORT FOR <br />PRIVATE SEWAGE SYSTEMS <br />CONVENTIONAL ❑ALTERNATIVE <br />Dfiolding Tank ❑ In -Ground Pressure ❑ Mound <br />SAFETY & BUILDINGS <br />DIVISION <br />BUREAU OF PLUMBING <br />State Plan I.D. Number: <br />(If assigned) <br />NAME OF PERMIT HOLDENR <br />WWa <br />ADDRESS OF PERMIT HOLDER: <br />/7"44, <br />/W/ <br />ATE: <br />INSPECTION Dl <br />vE—^ <br />BENCH MARK (Permanent reference poi ESCRIBE IF DIFFERENT FROM PLAN: <br />1 <br />TANK OUTLET ELEV.: <br />/ <br />REF. PT. ELEV.: <br />CST REF. PT. ELEV.. <br />� <br />PIT <br />fill Z� <br />)eo <br />6 <br />Name of PlumberMP/MPRSW <br />�� �✓i►w <br />Q 7 <br />No <br />I3d � <br />County:, <br />du112�t- <br />Sanitary Permit Number: <br />MANUFACTURER' • <br />WIDTH <br />1 � T <br />LIQUID CAPACITY. <br />/ <br />TANK INLET ELEV.: <br />f <br />TANK OUTLET ELEV.: <br />/ <br />WARNING LABEL <br />PROVIDED: <br />LOCKING COVER <br />PROVIDED: <br />TIONS MEASURED. <br />PIT <br />fill Z� <br />=PITS <br />6 <br />. �ni -� <br />BELE' PIPES / / <br />Q 7 <br />YES ONO <br />❑Trr_❑NO <br />BEDDING: <br />T DIA.:' <br />ME#'MATL <br />HIGH WATER <br />NUMBER OF" <br />ROAD: <br />VENT TO FRESH <br />AIR INLET <br />`!e� <br />LI <br />EDGES <br />WELL: a, <br />BUILDING: <br />VENT LE FRESHFEET <br />AIR INLET <br />1:1 YES El NO <br />PUMP <br />MANIFOLD <br />DISTR. PIPE <br />FROM <br />Z� <br />DISTR. PIPE <br />1PROPERT <br />�-��'ffyr <br />ELEV. <br />DIA. <br />DYES LINO <br />PIPES <br />❑YES ❑NO <br />NEAREST _ <br />/ <br />DOSING CHAMBER: <br />MANUFACTURER BEDDING. LIQUID CAPACITYPUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br />PROVIDED: PROVIDED: <br />DYES ONO OYES ❑NO DYES ONO <br />GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OFPROPERTY WELL BUILDING I VENT TO FRESH <br />(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: <br />PUMP ON AND OFF) OYES El NO NEAREST—Y <br />- - - -- <br />SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing - AMETEK MATERIAL AND MARKING <br />FORCE <br />or excavation. (If soil can be rolled into a wire, construction shall cease until <br />MAIN <br />the soil is dry enough to continue.) <br />nvcrc.a. <br />DIMENSIONS <br />WIDTH <br />1 � T <br />LENGTH <br />y r <br />/ <br />NO. OF <br />TRENCHES <br />ON REVERSE SIDE. SHOW ELEVA- <br />DISTR PIPE SPACING <br />� <br />COVER <br />MAT IAL: <br />TIONS MEASURED. <br />PIT <br />INSIDE DIA <br />=PITS <br />LIQUID <br />DEPTH. <br />. �ni -� <br />BELE' PIPES / / <br />FILL DEPTH <br />ABOVECOVER ELEV <br />„ ,. <br />UISTH- PULIPF <br />IN Fi <br />y <br />Q <br />DISTR. PIPE <br />ELEV-END <br />! e! <br />DISTR. PIPE. MATERIAL- <br />G <br />N .DISTR. <br />PIPES. <br />NUMBER OF <br />FEET FROM <br />NEAREST --►1 <br />PROPERTY <br />LINE: <br />3� <br />WELL. <br />BUILDING: <br />` <br />VENT TO FRESH <br />AIR INLET <br />`!e� <br />Mound site plowed perpendicular to slope <br />Check the texture of the fill material for <br />PROVIDE A DIAGRAM OF SYSTEM <br />and furrows thrown upslope: <br />mound systems to make certain that it <br />ON REVERSE SIDE. SHOW ELEVA- <br />LENGTH <br />meets the criteria for medium sand. <br />TIONS MEASURED. <br />OYES ONO <br />FILL DEPTH ABOVE COVER. <br />SOIL COVER ITEXTURE <br />PERMANENT MARKERS <br />OBSERVATION WELLS <br />TRENCHES. <br />❑YES ❑NO <br />EDNO <br />DEPTH OVER TRENCH <br />OVER TRENCH BED <br />TOPSOIL <br />SODDED <br />SEEDED <br />MULCHED <br />7DEIT. <br />CENTER <br />EDGES <br />171 <br />1:1 YES 1:1 NO <br />I ❑YES ONO <br />1:1 YES El NO <br />PRESSURIZED DISTRIBUTION SYSTEM: <br />bVIDTH <br />LENGTH <br />NO. OF <br />LATERAL SPACING: <br />GRAVEL DEPTH BELOW PIPE <br />FILL DEPTH ABOVE COVER. <br />BED/TRENCH <br />TRENCHES. <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 />ELEV. <br />ELEV. <br />DIA. <br />ELEV.. <br />PIPES <br />ELEVATION AND <br />DISTRIBUTION <br />OLE SIZE <br />HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. <br />VERTICAL LIFT CORRESPONDS TO APPROVED <br />INFORMATION <br />PLANS <br />❑YES <br />PERMANENT MARKERS: <br />E1 NO <br />OBSERVATION WELLS: <br />_ ❑YES ONO <br />UMBER OF PROPERTY JWELL: BUILDING: <br />EET FROM LINe: <br />TN <br />COMMENTS: <br />F-1 YES F-1 NO <br />❑YES El NO <br />EAREST— <br />Sketch System on <br />Reverse Side. <br />DI LHR SBD 6710 (R. 01/82) <br />Retain in county file for audit. <br />