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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABQR&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: IV CONVENTIONAL El ALTERATIVE (It assigned) J.14.,. S d -". ❑ Holding Tank CI In-Ground Pressure n Mound NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER: INSPECTION D TE: Y 11-1 -1 V 1---,..c-,..4\ REF,I I ELEV.:T REF.PT.ELEV.: BENCH MARK(Permanent refe point)DESCRIBE IF DIFFERENT FR M PLAN: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: v p ) ��, . '3.g-(c 1 ')∎vY-k-cc 8q ,0 S a- SEPTIC TANK/MOLDING-TAW: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER {� _ Q �_ PROVIDED: PROVIDED: /� C� � '` � O 0 07.65 ES El NO 07E--g- 0 N BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY ELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: _ _ AIR INLET: �KES ❑NO E YtS �❑NO _NEAREST—0, a5 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER �y PR VIDEO: R VIDED: Pt�c1i R '\YES ❑NO b O -I 1-1 Z ue L• -PV YES ❑NO YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY ELL: BUILDING: ENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLF�j: PUMP ON AND OFF) \_ LP ❑YES L�NO NEAREST— 0, Z S 7 S '7.?S SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: \ DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN 1 q c cp,� " the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO OF DISTR.PIPE SPACING: COVER INSIDE DIA.: 4.121T3' LIQUID BED/TRENCH / TREN HES: MATERIAL: PIT DIMENSIONS Ij �. o .2 , s GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END: PIPE : FEET FROM LINE:— AIR INLET: lot kv.■•,N w Lt ' el 4.5 )I. .3 S P V C NEAREST—► '7 7 S 0 '.?1. 7 e?" t's MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and fu rows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑V'• ❑NO meets t - criteria for medium sand. - EVATIONS MEASURED. SOIL COVER ' TEXTUR . PERMANENT MARKERS: OBSE- ATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH• ER TR INCH/BED DEPTHS OF TOPSOIL: SO.DED: SEEDED: MULCHED: CENTER: EDGES: _ ❑YES ❑NO ❑ S Nit NO ❑YES ❑NO PRESSURIZED DISTRIBUTION ' STEM: BED/TRENCH WIDTH: LENGT : NO.OF LATERAL SPACING: a- VEL DEPTH BELOW PIPE: DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP •ANIFOLD DISTR.PIPE MANIFOL a M TERIAL: NO.DISTR. DISTR.PIPE .IST'IBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV.: D •.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILL..CORRECTLY: COV•R MATERIAL: VERTICA LIFT CORRESPONDS TO INFORMATION APPROV I PLANS ❑YES ❑NO =I YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERV• ION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO NI YES ❑NO NEAREST-0, .,` -'-*-ID-P r\ 4A -4Q),->t.Q-ter,. ..t.,^ a-jz,‘ Z C"-"N 1 :l . ,, C, ., � Sketch System on Retain in county tile for audit. Reverse Side. SI AT RE_ TITL SBD-6710(R.06/88) 1 `