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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS <br /> DIVISION <br /> LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING <br /> P.O.BOX 7969 <br /> MADISON,W 153707 <br /> ElCONVENTIONAL ❑ALTERNATIVE <br /> Holding Tank ElIn-GroundPressure ❑Mound <br /> ADDRESS OF PERMIT HOLDER INSPECTION DATE <br /> NA OF PERM MOLDER. _, <br /> REF .ELEV.'. rLJCST REF PT.ELEV <br /> BENCHMARK(( ermal"IIIIIIIIII'DITOPfDRESCRUJI,IF DIFFERENT FROM PLAN <br /> Cnum Sannary Pormn Number. <br /> Narne nl Plumper'. MPIMPRSW Nn -7q(11-3 <br /> A <br /> . Rtt/HOLDING TANK: WARNING <br /> MANUFACTURER. r LIOUIU�ILAPACIT�V. TANK INLET ELtV TANK OUTLET ELEV HOVIDEDLA9EL PROVIDED OVE <br /> 1 <br /> DYES LINO ❑YIV ❑NO <br /> /e!/t HIGH WAiEH ROAD PROPEHTV WELL RV ILDIYG (VENT TO FRESH <br /> BEDDING'. VENT DIA. VENT MAT 1 NDMBER OF LINE �l �Fu, AIR INLET/ <br /> �,],L ALARM FEET FROM 4 GI r <br /> ❑VES NO L ' C-!`A '—]YES LINO NEAREST <br /> DOSING CHAMBER: <br /> MER <br /> ANUFACTURER BEDDING LIOLUI+{:APA(JIY PIIMI'MLII)FI V11MP.SIVI1(1N MA NLII AI:IUHt11 VP J(AR IDfOLABEL FROVIDEp OV <br /> DYES ❑NO <br /> —]YES ONO EYES ENO <br /> PUMP ANO CONT HO LSOPERAHONAL IN SER OF LINIEPF Hiv WELL dUILOINO AIR NLETHESH <br /> GALLONS PER CYCLE: FEET FROM <br /> LI <br /> (DIFFERENCE BETWEEN OYES ENO NEAREST 1 <br /> - <br /> PUMP ON AND OFF) INH R u1AMf IdJ, Man.Int nmu Mn.K w{. <br /> SOIL ABSORPTION SYSTEM.Check thesoil moistureat thedepth of PI WE ng .,FORCE <br /> OIL excavation. (If soil can be rolled into a wire,construction shall cease until -MAIN <br /> the soil is dry enough to continue.) <br /> CONVENTIONAL SYSTEM: Nsut Dln =Pl rs uDDID <br /> IN Or LENGTH NO OF ,,,III PIPE sPACINI� n+niE laAC' PIT DEPTH <br /> $ED/TRENCH':: rn 1.rvc HIE s <br /> DIMENSIDNS. It) NUMBER DF.. PROPERTY WELL BUILDING VENT TO FRESH <br /> RAVEL O H FILLDEPTH n1911 PIPf DIST. PIPE DISTR PIPF MATERIAL PIPES FH H LINE AIR INLET <br /> BE LDw PIPES ABuvE cavER EIFv INII I ELFv LNu FEET fROM <br /> NEAREST <br /> MOUND SYSTEM: <br /> Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- <br /> meets the criteria for medium sand. TIONS MEASURED. <br /> ElYES 0N Pl nn+nN,N 1 MAHKI HS D esEHVAnoNwllLs <br /> SOIL COVER TPxTUHe <br /> �]VE$ ❑NO _❑VES ❑NO <br /> DEPTH ovH TRENCH RBO DEPTH OVER rHENOH RE 11 nlPnl uE IUPS'uIl sOUDIu <br /> SFI Vfu MVLc.ED <br /> DEPTH EDGES ❑YES ❑NO <br /> DYES ❑NO Dy <br /> ��NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: Flu DEPTH ABOVE COVER <br /> BEDITRENCH: ..WIDTH LENfIiII TNO OF RENCHES LATERAL SPACING GHfrVEL UFYiH HF LVW PIPI <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISLR PIPE UISTIIIHV LION PIPE MAT ERIAL&MARKING <br /> IDES DIA <br /> ELEV ELEV. DIA ELEV. <br /> ELEVATION AND <br /> DI$TRIHUTION covEH MAreRIAL PLANS UFr coRREsvorvos TO APPRDVEo <br /> DISTfNFORMATION';�HOLE SIZE HOLE SPACIND DluufDCLUTICIIv PLANS <br /> EYES ONO DYES ONO <br /> NUMBER OF PHOPERTr WELL m N <br /> Btuc. <br /> COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. FEET FROM LINE <br /> ❑YES ONO ❑VES ❑Np NEAREST <br /> Retain in county file for audit. <br /> Sketch System on <br /> Reverse Side. TITLE <br /> SIGNATURE <br /> DI LHR SBD 6710 (R.01/82) <br />