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JU1-20-99 TUE 12:46 PM DDDHS NPO FAX NO. 608 242 6256 P. 04 <br /> Wisconsin Department Of Industry, ON SITE SEWAGE SYSTEM Safety&Buildings Division <br /> Labor and Human Relations INSPECTION REPORT <br /> P.O.so):79G9 <br /> Stale- 'a- <br /> MadM WI 53707 County: 0 (G r�,S ii <br /> CONVENTIONAL El AT-GRADE ❑IN-GROUND PRESSURE ❑MOUND (OWING TANK <br /> Elan I tIMENTAL 0 NEW ,.REPLACEMENT ❑RECONNECTION ❑OTHER(SPECIFY) <br /> PermrtHo aer•s Name: Permit Hol. s Address: Ins ctian Date: <br /> 1-4: 'e-S /71 t<Ottly C WI (Jell ui t/e- - i(c y ? , .�2 <br /> Be - Ma i XAestribe If Differen`ROM tan: Parcel Tax I.D.No,(Optional) e .Pt.Elev.: 1 CST Re .Pt.Elev.: <br /> f lumber 1; ,Iame: MP/MPRSW NO: e.-r" ------ <br /> a ,1 ,1err <br /> SEPTIC TANK/HOLDING TA` ' <br /> Manu Atli rer:- - Liquid Capacity: ' 'tank Inlet Elev.:ank Outlet Elev_: Warning Label lock mg Cover <br /> C- `-S000 NO 0 Pro 'dedes O No <br /> B Ufa: Vent Dia.: Vent Mati. N i g h Water Alarm: 'NUMBER OF Road: Property Line: Well: Burldln ; Au Vent: <br /> FEET FROM } Jr �z.S 7. S <br /> {; No Yes ❑ No NEAREST <br /> OSING.:HAMBER: , <br /> — <br /> Manu aeii'rer: ` Bedding: Liquid Capacity: Pump ••e: Pump.Si• on Manu acturer: High WaterA arm Warning Label Locking Cover <br /> ❑Yes (] No Provided: Provided: <br /> ❑Yes ❑No 0 Yes 0 No ❑Yes ❑No <br /> a sPi!'Cycle: Pump andtontro(sOperational: NUMBER Propertytine: well: 8ui ing: Air Vent: <br /> (different• between FEET FROM <br /> oump Oft•sndoff) ❑Yes 0 No • NEAREST--± <br /> Vent Installed:— Vent Diameter: Vent Material: Length: ` Diameter: Mattenal aria Marking: <br /> VENT I FORCE <br /> ❑ Yes 0 No _ MAIN <br /> SOIL AS RPTION SYSTEM_ Check the soil moisture at the depth of plowing Or excavation. (11 soil can be rolled into a wire.construction shall cease until <br /> the soil is J ry enough to continue.) <br /> DISTRIBUTION STSTEM: <br /> dEDJTREIICH Width: Length: No.Trenches: Lateral Spacing: Cover Material: Inside Dia; No.Pits: Liquid Depth: <br /> . DIMENSIC NS PIT <br /> Caravel Bei(w Pipe FillAbove Ptpe: Inlet Elev.: End Elev.: Pipe Material, No.Distr.Pipes: NUMBER OF Property Line: Well: Buitdeng: Air Vent: <br /> FEET FROM <br /> i t NEARESTf _ <br /> Manifold Elev.: Maniii)Id Dia.: Manifold Material: No.Distr.Piper �Distr.Pipe Dia.: <br /> ELEVAT1C I I AND <br /> DISTRIBU I iON . <br /> INFoRMAl1ON H e Size: Hole Spat i Drilled Correctly: Permanent Marken Observabon Wells: Pump Elev.: Vertical Lift Corresponds To <br /> Approved Plans: <br /> ❑ Yes ❑ No ❑ Yes ❑ No ❑Yes ❑ No _ ❑ Yes ❑ No <br /> MOUND SYSTEM: _ <br /> Mc and site.plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM <br /> slot se 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 /> Texture: Permanent Markers: Observation Wells: <br /> SOIL COV1 E <br /> ❑ Yes ❑ No C) Yes ❑ No <br /> e�J ptw; rent Be enter: Depth yr r Trench Bed Edges: Depths Of Topsoil: Sodded: 'Seeded: Mulched: <br /> Q Yes ❑ No ❑ Yes 0 No ❑ Yes 0 NO <br /> COMMEN I is(Sketch System On Reverse Side 1 . <br /> ( op 0 T TC._c„.. ( c Lrt°� <br /> J! f-..,, I_- i.^'■ / J / i S [ J -' U 6^ l <br /> ,\)c—fl) <br /> .— • <br /> . 10 4 <br /> 1/ J <br /> M <br /> }�--) _ 177A- <br />