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4 <br /> DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING <br /> LABOR&IiUMAN RELATIONS DIVISION <br /> P:O.BOX.7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION <br /> MADISON,WI 53707 <br /> State Plan I.D.Number <br /> A -NW SEC• 3 X CONVENTIONAL ❑ ALTERATIVE (If assigned) <br /> ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound <br /> NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: <br /> n reference 443 E. 1 o-{ rrn 6.'.i-Curr...�iva G<,'.,r. . /2 • S'- 89 <br /> NCH MARK(Permanent poi ) . REF.PT.ELEV.: CST REF.PT.ELEV.: <br /> '/'},/.o` di 4 7WA.A. .5'4-0-4- /o o /00 <br /> Name lumber: MPNApfBNM o.: County: Sanitary Permit Number: <br /> £ al-o- 64):,, ,:i_--'f'7_ s 3 z .rte�,.c _ /z 9.3 S 6 <br /> SEPTIC TANK/UO 11 TAK: S?f 0 6-93 <br /> MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER <br /> . ."?'77 �/ - /000 � _ ` 9/, /3 '/. CO PROVIDED: PROVIDED: <br /> .IGr� VR+4 ❑YES NO ❑YES ENO <br /> BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH <br /> II ALARM: FEET FROM LINE: 0 I AIRIN T <br /> WYES ❑NO 4 ❑YES 6�NO NEAREST—► Ah4 >z/ a Z.s >5 /1 /� <br /> DOSING CHAMBER: <br /> MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER <br /> PROVIDED: PROVIDED: <br /> El YES El NO ❑YES El NO El YES Cl NO <br /> GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH <br /> (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: <br /> PUMP ON AND OFF) ❑YES ❑NO NEAREST—0 <br /> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: <br /> or 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: <br /> WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID <br /> DIMENSIONS I / , /� TRENCHES:H � /_ • MATERIAL:_ , PIT DEPTH: <br /> GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: _NNO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH • <br /> BELOW PIPES: I ABOVE COVER: ELEV.INLET: ELEV.END: PIPES: FEET FROM LINE: I I I AIR INLET: $ <br /> .7S-.47 24-34" 111.S2 87,4+ 2729 3 NEAREST—Po' >S LSD >25 A=S <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 /> El YES El NO meets the criteria for medium sand. ELEVATIONS MEASURED. <br /> SOIL COVER I 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 /> ❑YES ❑NO _ El YES ❑NO ❑YES El NO <br /> PRESSURIZED DISTRIBUTION SYSTEM: <br /> BED/TRENCH WIDTH: LENGTH: NO OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER .- <br /> TRENCHES: <br /> DIMENSIONS <br /> MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: <br /> ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: <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 /> -1)4.- /31-472.41.i a..e.e%.,....4,-s... 4.44164-" 67,01-4-27 viiii 4H k i...❑YES El NO ❑YES El NO NEAREST�► <br /> Sketch System on ,0 <br /> Retain in county file for audit. <br /> Reverse Side. SIGN E: TITLE: <br /> SBD-6710(R.06/88) 1' •`+/ <br />