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A Wisconsin Department Of Industry, ON SITE SEWAGE SYSTEM Safety&B ildings//Division Labor and HUrnan Relations INSPECTION REPORT ' �r% , I to P.O.Box 7,969 ' Madison,WI 53707 County: eniVe CONVENTIONAL ❑AT-GRADE ❑IN-GROUND PRESSURE 0 MOUND LT ( CT O� .0 EXPERIMENTAL ❑NEW MREPLACEMENT ❑OTHER(SPECIFY) ❑RECONNECTION ❑OTHER(SPECIFY) Perm)it Holder's(lame: - Permit old is A.d,.drres,ss� I - Inspection Date: Bench Mark.Describe If Different From Plan: ��E1`•' / �' �j -Z�>� Parcel Tax I.D.No.(Optional) Ref.Pt.Elev.: CST Ref.Pt.Elev Plum 's Name: "- MP/MPRSW No State Plan 10 No.(If Assigned): Sanitary Permi Number: SEPTIC TAN HOLDING TANK: Manufacturer: - li idCapacity: - Tank Inlet Elev.: Tank Outlet Elev.: - Warning label Locking Cover • 7 5s-V 3 95.L.3 Pr ided: Provide • , Yes,erNo I ❑ Yes fp No Bedding: Ve t Dia.: V t'L: High Water Alarm: NUMBER OF Road: Property Line: Well: Building: Air Vent: Yes 'Q No �4 FEET FROM 7 2,e ',2s- 7 ❑Yes ., o NEAREST--± [-tU �� DOSING CHAMBER: Manufacturer: Bedding: Liquid Capacity:Pump Model: Pump/Siphon Manufacturer:High Water Alarm -Warning Label - Locking Cover •• Provided: Provided: , ❑ Yes ❑ No ❑Yes ❑No Q Yes ❑No ❑Yes ❑No Gallons Per Cycle: Pump and Contro s Operational: NUMBER Property Line: Well: Building: Air Vent: (difference between FEET FROM um on and off) • l Yes fl No - NEAREST-* Vent Installed: Vent Diameter: Vent Material: Length: Diameter: •Material an VENT FORCE and Marking: ❑ Yes ❑ No , MAIN SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing or excavation. (If soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.) DISTRIBUTION STSTEM: _ - BED/TRENCH Width: Length: No.Trenches: Lateral Spacing:-Covers l:- Inside Dia: No.Pits: Liquid Depth: DIMENSIONS J "`]�'' —1/" PIT 'Gravel Below Pipes Fill Above Pipe: Inlet Elev.: End E) v.: P' aterial; No. tr.Pipes: NUMBER OF 'Property line: Well: B ilding: Air Vent: 6-S N • 'gyp-(f 5ers. P.M al; FROM NEAREST-g. 7S 7 sa ELEVATION AND Manifold Elev.: Manifold Dia.: Manifold Material: No.Distr.Pipes: Distr.Pipe Dia.: • DISTRIBUTION INFORMATION Hole Size: Hole Spacingr Drilled Correctly: Permanent Markers Observation Wells: Pump Elev.: Vertical Lift Corresponds To • Approved Plans: 0 Yes 0 No Yes ❑ No 0 Yes ❑ No Yes MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ Yes ❑ No . meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I Texture: Permanent Markers: Observation Wells: . • ❑ Yes 0 No ❑ Yes ❑ No Depth Over Trench Bed Center: Depth Over Trench Bed Edges: - Depths Of opsoil: Sodded: -Seeded: Mulched: ' • ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS:(Sketch System On Reverse Side "4 .4 `) t--ac. 9O .4 . ).4. "t) 1 '. )l 00414 N eivittli Signature: Tute: