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I1- -7- <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 State Planl.D.Number: <br /> CONVENTIONAL ❑ ALTERATIVE (If assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAMEOF-PERMIT HOLDE : ADDRESS OF PERMIT HOLDER'. INSPECTION DATE <br /> JPc� 6c aL(- kLT- u I-r7 -9 <br /> BENCH MARK(Per anent referencepoin' DESCRIBE IF DIFFERENT FROM PLAN: REF.PL ELEV.: CSTR E PT.ELEV.. <br /> Nameot lumber. CJ/�-//17t•,jr'y'1 MPIMPRSW No' Coun Sanitary Permit Number' <br /> an <br /> 3�q3 fur 13�❑�g Iq <br /> SEPTIC TA /HOLDING TANK: <br /> MANUFACTURER- / LIQUID���gggPACITY: TAN NLETELEV.: TANK QUTLET ELEV.'. WARNING LABEL LOGKI NGCOVER <br /> 1 p( l,� �1 � PROVIDED'. PROVIDED'. <br /> [•J G YES [--]NO $i`[r$N10 <br /> BEDDING'. VENT DIA. VENT MATL.'. HIGH WATER NUMBER OF ROAD: PROPERT WELL: BUILDI�- VENT TO FRESH <br /> .1— ALARM: FEET FROM ` �7 LIN / ryr/� / AIR INLEL <br /> ❑YES NO 4" `t NEAREST�� / J T"- <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING'. LIOUIDCAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOOKING COVER <br /> PROVIDED: PROVIDED: <br /> ❑YES ❑NO ❑YES ❑NO ❑YES LINO <br /> GALLONS PER CYCLEPUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL'. BUILDING'. VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET. <br /> PUMP ON AND OFF ❑YES ❑NO NEAREST---IIII <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowingFORCE LENGTH: DIAMETER: MATERIAL AND MARKING. <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN <br /> ihes I is dry_nought-continue.) <br /> V NTIONAL SYSTEM: <br /> WIDTH- LENGTH NO OF DISTR.PIPESPACING: COVER INSIDE DIA a //PITS: LIQUID <br /> ED/T ENCH �/ �� TRENCF : Lrye MATERIpLI p1T <br /> DI SIONS S.+F'. <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR PIPE DIST .PIPE MATERIAL: .DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> BEL `PIPES'. ABOVF�{.AVFIR E .L T: ELEV.$ND 0 PIPE FEET FROM `INE- IL / <br /> rYl� .7f / NEAREST I <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 ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS: <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL'. SODDED: SEEDED: MULCHED' <br /> CENTER'. EDGES: <br /> DYES EDNO ❑YES ❑NO ❑YES ❑NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH'. LENGTH NO OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER <br /> RENCHES <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING'. <br /> ELEVr. ELEVI. DIA.'. ELEV. PIPES: DA.: <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL'. VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ❑YES ❑NO ❑YES ❑NO <br /> PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING'. <br /> COMMENTS: FEET FROM LINE: <br /> Q ❑YES ❑NO ❑YES ❑NO NEAREST <br /> AI <br /> Lv 0A5 <br /> etain irbcounty f l e for and it. <br /> Sketch System on <br /> Reverse Side. sICNATuae TITLE <br /> SBD-6710 IF 06/88) <br />