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DEPARTMENT of INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.Boz 7469 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON.WI 53707 <br /> State Plan I.D.Number. <br /> L-1CONVENTIONAL ❑ ALTERATIVE j0 assieno <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PFPMIT HOI DER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Q <br /> BENCH MARK mermanate reference point)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT ELEV.'. CST REF.PT.ELEV.: <br /> Name of Plumber. MPIMPRSW No County Sanitary Permit Number: <br /> SEPTIC TANK/HOLDING TANK: <br /> MANIIFA nER LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> PRO IDED: PROVIDED'. <br /> C( Ca �DU i YES [:1 NO LJ YES O <br /> BEDDING. VENT DIA.' VENT MATO HIGH WATER NUMBER OF - ROAD'. PROPERTY WELL: BUILDING: VENT TO FRESH <br /> (( (' ALARM. FEET FROM -7 UNE-y / AIR INLET' <br /> ❑YES NO C�J ❑YES O NEAREST 7/ s- / r �i �— <br /> DOSING CHAMBER: <br /> MANUFAC ER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER <br /> p <br /> PROVIDED <br /> YES ❑NO W YES ❑NO <br /> (L ❑YES NO d20DG� � � �0 Z6 P� Q�— <br /> ALLONSPERCYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL'. BUILDING'. VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM N S /Q� 7AIR INLET. <br /> PUMP ON AND OFF E$ ❑NO NEAREST—I i <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER. MATLHIALP",MARKwG <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN �7_j h ,, _ / a <br /> the soil is dry enough tocontinue.) / 3 /i�/I <br /> CONVENTIONAL SYSTEM: _ <br /> BED/TRENCH WIDTH. LENGTH: NO OF DISTR.PIPE SPACING: COVER INSIDE DIA.'. #PITSLIQUID <br /> DIMENSIONS TRENCHES: MATERIAL: PIT DEPTH <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DISTR. NUMBER OF PROPERTY WELL'. BUILDING'. VENT TO FRESH <br /> BELOW PIPES'. ABOVE COVER'. ELEV.INLET. ELEV.END: PIPES: FEET FROM LINE'. AIR INLET. <br /> NEAREST—♦ <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW <br /> ❑YES LINO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOIL COVER TEXTURE'. PERMANENT MARKERS- OBSERVATION WELLS, <br /> _ ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCHIBED DEPTH OVER TRENCWBED DEPTHS OF TOPSOIL SODDED SEEDED: MULCHED: <br /> CENTER. EDGES: <br /> _ ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM:BEDIT ' <br /> WIDTH- LENGTH'. NO.OF LATERAL SPACING: GRAVEL DEPTH BEL OW PIPE- FILL DEPTH ABOVE COVER' <br /> DIMENSIONSENCH <br /> - / TRENCHES. / i !c /,� - , <br /> DIMENSIONS ( 7 /';l_ <br /> oZ 0 W as �pZ <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING <br /> : <br /> ELEVATION AND ELE r' ELEV / o DIAa !( E `Q �� PIPES DIA ,� �O <br /> DISTRIBUTION Ho SIZE:l� HOL P LING. DRILLED CORRE TLY. COVER MATERIA - VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION n /J y/ APPROVED PLANS <br /> YES ❑NO 1, L (lj-�YL- YES ❑NO <br /> PERMANENT MARKERS'. OBSERVATION WELLS. HUM OF PROPERTY WELL BUILDING: <br /> COMMENTS: FEET FROM NE / <br /> YES ❑NO YES 0N NEAREST---- S 7/ad 7 <br /> 953. E 9. 77 <br /> l lr� �i;:/Clih Cl'S7anreJ wI � -98� <br /> 40�era f — 7�5 1p.3Q �o�am7� 7tU4— Ill?. 31 <br /> J <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. SIGNATURE: <br /> SBD-6710(R.06/88) j Z <br />