Laserfiche WebLink
DEPARTMENT OF INDUSTRY. INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&HUMAN RELATIONS DIVISION <br /> Pi BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON.Vr'I 53707 1 State Plan I D.Number. <br /> CONVENTIONAL ❑ ALTERATIVE (Itassigned) <br /> ❑ Holdng Tank ❑ In-Ground Pressure ❑ Mound <br /> NAMEQi M I T HOLDER: ADDRESS OF PERMIT HOLDERdG56 G,; ,c/wrnxl R - <br /> INSPECTION DATE: <br /> ha <br /> BENCH MPF K(Permanent r terence point)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: CST REF.PT.ELEV.'. <br /> �l�h1L r Q w �16tr9 4o <br /> Name of Pl;vioor MP/MPRSW No.: County: Sanitary Permit Numb <br /> pr10`�i-� o'_N �����ll <br /> SEPTIC TANK/HOLDING TANK: ' <br /> MANUFACTURER: LIQUID CAPACITYP. TANK INLET ELEV. TANK OUTLET ELEVr. WARNING LABEL LOCKINGCOVER <br /> PROVIDED: PROVIDED. <br /> YES ❑NtE77E_S_=N0 <br /> BEDDING. VENT DIA. VENT MATL.'. HIGH WATER NUMBEfl OF ROAD- _ PROPERTY WELL: BUNT TOFRESH <br /> (.� // ALARM. FEET FROM jj / LINE INLET❑YES [NO / Ca,s 'E7 YES�.No NEAREST � .)Q / �� ' <br /> DOSING CHAMBER: <br /> MANUFACTURER BEDDING: LIQUID CAPACITY: PUMP MODEL PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> I/ PR VIDED'. PROVIDED'. <br /> EI YES NO 7 SO SC/rr 33 I 1- �!f r/ YES ElNO YES ❑NO <br /> GALLONS PER CYCLE'. PUMP AND CONTROLS OPERATIONAL NUMBER OF P`RNOPERTY WELL: BUILDING: VENTTOFRESH <br /> (DIFFERENCE BETWEEN FEET FROM JE d / ?�/ AIgLN,:/ <br /> PUMP ON AND OFF YES FN O NEAREST-� / t- sJ� <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of png FORCE LENGTH: DIAMETER. MATERIAL AND MARKING: <br /> or excavation. (If soil can be rolled into a wire,construction shall cease until _[ //a _�;Sf •7GG /7� <br /> the soil is dry enough to continue.) <br /> MAIN cn 77 Ot <br /> CONVENTIONAL SYSTEM: <br /> WIDTH'. LENGTH' NO.OF DISTR.PIPE SPACING: COVER INSIDEDIA.: $PITS'. LIQUID <br /> BED/TRENCH TRENC : MATERIAL: DEPTH <br /> DIMENSIONS a�/ HESPIT�— r M44 PA �-� �` ./ <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH <br /> BELOWPIPES: ABOVEGOVER ELEV.INLET'. ELEV.ENP. /� .( PIPES- FEET FROM LINE 2 , ��s, T AIR INLT / <br /> I/)/� �t� p % Q /TSI 27r�� NEAREST♦ /✓ ✓ >7J <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 /> SOILCOVER j TEXTURE'. PERMANENT MARKERS: OBSERVATION WELLS. <br /> ❑YES ❑NO ❑YES ❑NO <br /> DEPTH OVER TRENCH/BEC DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED ISEEDED- MULCHED'. <br /> CENTER'. EDGES. <br /> _ I _❑YES LINO ❑YES ❑NO EYES [--]NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: ND OF LATERAL SPACING: GRAVELDEPTHBE LOW 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 /> ELEV.: ELEV(. DIA. ELEV: PIPES'. DIA.'. <br /> ELEVATION AND <br /> DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILL ED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO <br /> INFORMATION APPROVED PLANS <br /> ElYES ❑NO ❑YES ❑NO <br /> PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL'. BUILDING. <br /> COMMENTS: FEET FROM LINE: <br /> ❑YES ❑NO ❑YES ❑NO NEAREST---- <br /> -�� � <br /> 3, <br /> 4 <br /> f41'471" q� 3 <br /> It <br /> V�q �� l <br /> Sketch System on Retain in county file for audit. L'7 ' <br /> Reverse Side. SIGNATURE 0, <br /> SBD-6710(R.06/88) <br /> N /{ i <br />