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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION <br /> P.O.BOX 7969 BUREAU OF PLUMBING <br /> MADISON,WI 53707 <br /> ®CONVENTIONAL ❑ALTERNATIVE Istate Plan LD.Number: <br /> Ilt assigned) <br /> ❑Holding Tank ❑ In-Ground Pressure ❑Mound <br /> NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER. INSPECTION DATE <br /> E NCH MATTK ennanert reference point)DESCRIBE IF DIFFERENT FROM PLAN. / I, REF.PT.ELEV.: CST REF.PT ELEV. <br /> Name of PWmneo MPiMPRSW No.. Counry sanitary Permit Number: T <br /> d't�61 6� �Ler1 <br /> SEPTIC TANK/HOLDING TANK: <br /> MANUFACTURER LIOUI D CAPACITY. TANK INLET ELEV TANK OUTLET ELE V.: WARNING LABEL LOCKING COVER <br /> / I T/ PROVIDED: PROVIDED <br /> L'�' r 3/ 1 3YES ❑NO OYES ❑NO <br /> BEDDING: VENT �: VENT MATL HIGH WATER NUMBER OF 'IF ROAD: PROPERTY WE BVILDIN13 VENTTOFRESH <br /> ALARM FEET LINE _ :AIR INLET <br /> OYES LRINO u / GF ❑YES ❑NO NEAREST, T Li L GS ✓ �� <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MOREL PUMP,'SIPHON MA NUFACTUREH WARNING LABEL LOCKING COVER <br /> PROVIDED. PROVIDED: <br /> EYES ❑NO I I I I DYES ❑NO ❑YES ❑NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF IPROPERTY WELL BUILDING I VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEE T'FROAli LINE. AIR INLET: <br /> PUMP ON AND OFF) DYES ONO NEAREST <br /> SOIL ABSORPTION SYSTEM.Check the soil moistureat the depth of plowing LENGTH oIAM ETCH MATERIAL AND MARKING <br /> or excavation. I 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 /> WIDTH LENGTH NO.OF DISTR PIPE SPACING COVER INSIDE DIA. SPITS LIOUID <br /> BE TRE <br /> / / 7HES ht TERIAC PIT DEPTH <br /> -1 : <br /> DIMENSIONS I) <br /> GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.D NUMBER OF PROPERTY - BUILDING. VENT TO FRESH <br /> BE LOWPIPES ABUVECDVER ELEV.INLET ELEV END PIPES LINE. v' <br /> ? // r FEET FROMNEAREST f )CS / AIR INLET <br /> 7 <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 PERMANCNT MARKERS OBSERVATION WELLS <br /> DYES ONO OYES 1:1 NO <br /> DEPTH OVER TRENCH:BED DEPTH OVER TRENCH,BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED <br /> CENTER EDGES <br /> ❑YES ONO L]YES ENO DYES ONO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. <br /> BED/TRENCH TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANI FOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. <br /> ELEV, ELEV. DIA. ELEV.. PIPES. DIA.: <br /> ELEVATION AND <br /> DISTRIBUTION <br /> INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED <br /> PLANS. <br /> 1:1 YES [:1 NO I DYES ONO <br /> COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF a PROPERTY WELL: BUILDING: <br /> FEET FROM ', <br /> DYES LINO OYES 1:1 NO NEAREST `. <br /> Sketch System on Retain in county file for audit. <br /> Reverse Side. <br /> SIGNATURE: TITLE <br /> v <br /> DILHR SBD 6710 (R.01/82) G / ! Z `r%'2 r ✓�' , ��� r � r�- <br />