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67) <br /> REPORT ON INSPECTION OF SANITARY PERMIT # o- <br /> 1 Name and Address of Permit Holder Person/Persons at Site (2)Date <br /> of Insp ction <br /> 'Name, ress, icens o 4 ns a ling Plumber Tim of nspection <br /> J,c%-e <br /> (3)INSTALLATION CONSISTS OF: O� epp�tic Tank ❑ Seepage Trench []Dosing Chamber <br /> ❑Seepage Pit L 9-epage Bed ❑ Holding Tank ❑ Fill System <br /> ermanen re erence in Describe: <br /> Elevation of vertica�ference point: / ( -0 Slope at site: <br /> (5)MATERIAL AND DEPTH OF SEWER: <br /> (6)SEPTIC TANK: Manufacturer: Liquid Capacity: n'd <br /> Tank Inlet Elevation: Tank Outlet Elev: /p <br /> # ft to lot or property line: > 414t, # ft to well : > <br /> M DOSING TANK: Manufacturer: # of gallons : J <br /> # of gallon pump set for a cycle gallon a capactiy of distribution <br /> lines gallon; size of pump head; gallon per minute ; <br /> horsepower brand nam pump and mo umber <br /> Is the warning device install YES ❑NO Wired? -]YES ❑NO <br /> 8 HOLDING TANK: Manufacturer # of gallons ; <br /> construction depth to the cover ft; If septic tank is <br /> being used are baffles removed? YES [:] NO- ft from residence; <br /> ft from well ; ft from p ine. Type of warning device <br /> Is the warning device installed? ES Cl red? OYES [:] NO; <br /> Locking device on cover? ES ❑ NO; Diameter of ven and material ; <br /> Distance from building to vent <br /> (9) SEEPAGE PIT SIZE: f pits; ft diameter; ft liquid depth; <br /> ft to residence; ft t 11 ; ft -to property line; <br /> ft to ordinary high water mark of ream; ft to edge of slopes <br /> greater than seeps e n et pip - tion ft; bottom of <br /> seepage pit elevation t. <br /> (10) SEEPAGE BED SIZE: ft width; ft length; t le depth; <br /> _� r lineal feet tile; S-G ft to residence;>JBO ' ft to well ; y /,Z eft to lot or <br /> property line; ft to ordinary high water mark of lake or stream; -2-5" ft to edge <br /> of slopes greater than 20% falling away toward lake, water courses or drainage ditches <br /> Elevation of tank discharge line entering bed 17,? ft. <br /> 11 SEEPAGE TRENCH: Total lengthof seepage trench ft; width ft; <br /> tile depth ft; well ; ft to ordinary high water mark of <br /> lake or stream; ft to edge o es r an 20% falling away toward lakes , <br /> water courses or drainage ditches; el tank discharge line entering seepage <br /> trench ft. l -- <br /> (12) Has system been installed in area indicated on EH 115? []YES ❑ NO <br /> (13) Has system been installed in floodway? ❑YES ❑NO Floodplain? []YES ❑ NO <br /> DILHR-SBD-6095 N.0 /8 / IV <br /> rL ' ci, --- <br /> Signature of Inspector: �L`��y��� _ <br />