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Home My WebLink About161-1094-95-000 p y . d O (D CD 3 O m o C m j 2 AND - - CD CD ( O d. z a 1 N N? N O 1 O w cN`O c= w w5 l o o CO w N w N v i -0 3 Q O CD C) O O co CD n w CJ7 (D C17 W CT ro ::r 0 O !~`l = N = O O !V M U) a O 22 CD w G O u> C D CD (f] (n N d O 7 N W :3 N Q 3 o O a O N N m CO L O z o CD co co S O C N N N c !r C 3 0 0 0 o z 0 0 0 t!`11 Z~t a~ it .A o N "0 N c 0 0 0 -5 C: N CO 0 0 0 v~ D O n 0 0 0° m o 0 0 0 w CD 0 CD C/) N C(D CL N z z co Z O 0 D a = m y CD m C c m w m 0 CD --j cn oz O p Z ID N C :3 p z O 0 n O W - * w a z 3 z o z CD I w ~ a I a I o - T w c oz Co N I i A 4 fi ~ I N a I N O O a A 0 c., ~ I A N CD ai Efl 0 V O :E p yb b (D 0 CL v y ARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS 30R & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION J. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ❑CONVENTIONA4_, ❑ALTERNATIVE S(if tate Plan ID Number J`i j assigned) ❑ Holding Tank In-Ground Pressure ❑ Mound NAM F PERMIT HOLDER. ADDRESS O ERMIT HOLDER INSPECTION DATE. U e & v r Y ~~~T r 01,7 BENCH MARK Permanent ter-c- point) DIF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. Ilk 46 Name of lumb jMPMPRSV1 No. JCounty Sanitary Permit Number: ;2 ye 7A 32(I SEPTIC TANK/HOLDING TANK: c' MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL KL0CK:Q ING O R P OV DED. O: G YES ❑NO VS NO BEDDING. VENT CIA VENT AT L. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING V T TO FRESH AL M FEET LINE. "I ET. YES ❑NO ES ❑NO INEARES~M DOSING CHAMBER: MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL L CKIN COVER 7 f J J PRO DED. PR ED ❑NO YES ❑NO YES ❑NO GALLONS PER CYCL PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BU DI , VENT TO FR.' (DIFFERENCE BETW EN FEET FROM ye ASR INL PUMP ON AND OFF) YES ❑NO NEAREST-~► ` Ll '4 SOIL ABSORPTION SYSTEM. Check the soil moisture at t,6 clpthofplowing 'Fl, T7 ❑In`rIrER MArERIALA MARJING or excavation. (If soil can be rolled into a wire, co struction shall cease until L FORCE V the soil is dry enough to continue.) MAIN 3 C ~6 U CONVENTIONAL SYSTEM: I,NIDTH. r/ Hill NO. 91F DISTR. PIPE SPACING. COVEH Ts' DE DIA. SPITS LIQUID BEd/TRENCH TR cH s MATERIAL: PIT DEPTH DIMENSIONS rFI FILL DEPTH 1715 .i Plf F DIST .PIPE DISTR. PIPF. MATERIAL : Pi F DISTR NUMBER OF PR OPERTV WELL. BUILDING. VENT TO FRESH HF I!iW PIP[ F ()VF COVER EL V IN E ELE END. PPES. LINE AIR INLET_ FEET FROM NEAREST MOUND SYSTEM: O Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO _ SOIL COVER. TEXTURE PERMANENT MARKERS OBSERVATION WELLS I ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH, BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED. CENTER EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: W 17,'1 11 LENGTH NO. OF LATERALSPACING. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES / DIMENSIONS `r %ANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIP A~IAL & MARKING. ELEV ELEV. DIA. ELEV. 'r' PIPES. DIA.'. ELEVATION AND DISTRIBUTION / ~-gr HO~f' El 7- HOLE SPACING DRILLED CORRECT LY ' r CVERTICAL LI ORRESPONDS TO APPROVED i INFORMATION / PLANS L _ -3 4 YES ❑NO `ES ❑NO COMMENTS: PERMANENT ARKER JOBSERVATION WELLS: NUMBER OF : PROPERTY. WELL: BUILDING: FEET FROM LINE YES ❑ NO YES El NO NEAREST ° L S Sketch System on __...:fie in ounty file for audit. Reverse Side. SIGNAT14FrF_ w TITLE. y' r'? DILHR SBD6710 (R.01/82)- j DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BU!LDI LABOR F~HUMAN RELATIONS DIVISIO PRIVATE SEWAGE SYSTEMS f~ P.O. BOX {69 BUREAU OF PLUMBING MADISON", WI 53707 X CONVENTIONAL ❑ ALTERNATIVE IS,,,, PI," I Number Ilf assigned) El Holding Tank ❑ In-Ground Pressure F-1 Mound NAME PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. BEN, MARK Permanent -fer. e porn, CRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. 11 t,~' it - 7 rl - J ~~'lck 11 E Nt e of Plumber MPIMPRSW No.. 1"'"'y Sanitary Permi, Number art - - II lr/ J a i SEPTIC TA /HOLDING TANK: j 7 MANUFACTURER LIQUID CAPACITY. TAN K'IN LET ELE V.. TANK OUTLET ELEV. IWARNING LABEL LOCKING CO PR VI D PROVI D ~2✓Lr/L~~~ / 2 Z- l LY ES LI NO NO IVEY'F TO FRESH BEDDING: VENT DI VENT MAT HIGH WATER UMBER OF ROAD PROPERTY WELL B ALARM LINE J AIR IX NT C FEET FROM YES LINO NEAREST 1 - OS NG CHAMBER: MANUFACTURER BEDDING. LIQUID CAPAP11MPAN.PCONTROLS UMP MODEL PUMP/SIPHO ANUF T RE WARNING LABEL LOCKING COVER PROVIDED PROVIDED: OYES LINO OYES LINO OYES ❑NO_ GALLONS PER CYCLE: OPERATIONALUE7 OF PROPERTY WELL BUILDING VENT TO FEES (DIFFERENCE BETWEEN ONE AIR INLET PUMP ON AND OFF) YES ONO SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Fb CE ~n I. ar.,t TER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until ] the soil is dry enough to continue.) I IN CONVENTIONAL SYSTEM: BED/TRENCH WIDTHn LENGTH NO. OF DISTR. PIPE SPACING COVER - INSIDE A. -PITS. LIQUID TRE NCHES hi6 1Al -PIT - DIMENSIONS ~ (t: DEPTH. / c PRO ERT WELL. BUILDING: VENT TO FRESH 7 7 " I ~ , FILL DEPTH DIS1H PIPE DISTR PIPE DISTR. PIPE M TER I A L NO D,1' NUMBER OF I' r5 AB VECOVER ELEV.INLFr EL v((END --7 PIP FEET FROM ILIN ~ AIR~NLET~ ~~J•~'~ / NEAREST ~~CJ(/T MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material or PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain at it N REVERSE SIDE. SHOW ELEVA- meets the cri eria for medium san ION EASURED. EYES LINO SOIL COVER. TEXTURE ERMANE T MARKERS. OBSER VA T ION WF L L S YES LINO EYES ONO DEPTH OVEN TRENCH RED DEPTH OVER TRENCH; BED DEPTH OFT S IL. SOD D S EDED MULCHED CENTER EDGES. EYE ❑ OYES LINO OYES LINO PRESSURIZED DISTRIBUTION SYSTEM: _ WIDTH LENGTH. NO. OF LRAL PACING. G AVEL DEPT BEL PIPE. FILL DEPTH ABOVE COVER. ABED/TRENCH TRENCH Es DIMENSIONS MANIFOLD PUMP MANIFO D D STR PI E MA IFOLD MA ERIAL. NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING Et.FV.. ELEV. CIA. LEV. PIPES DIA. ELEVATION AND ,DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRIL ED CORN CTLY CO ER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED . ❑Y S ❑N PLANS EYES ONO TERVATION BUILDING COMMENTS': PERMANENT MARK RS WELLS NUMBER OF PROPERTY WELL: FEET FROM (LINE OYES NO OYES LINO NEAREST 1 C: - g4j L V c~ Z yc Sketch System on unty file for audit. Reverse Side. SIG TITLE. DIL_HR SBD 6710 (R. 01/82) - DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION ,LABORAND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: Property Location: _ City, Village or Township: County: NGU %Nk),IS 13 iT 29 NiR 20 E (or) W ,Vla 7y 110VS0-t! 57{ < Lot Number: Blk No:: Subdivision Name: p 7 Nearest Road, Lake or Landmark: State Plan I. D. Number: 2-1 ,9~' a0yX (If assigned) TYPE OF BUILDING F~/~ ,V17 Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY Qatf J( HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: E- 'e- &AMEv OG EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOS D (Square feet): IX New ❑ Replacement ❑ Experimental ^ Seepage Bed ❑ Seepage Pit AOx 3- ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signat MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: 'I Zz- 1y0A yD~ j!~ /t/DrP - U~sp v ~v/S COUNTY/DEPARTMENT USE ONLY 1igna re of 1 g Aggnt: Fee:: Date: APPROVED Sanitary Permit Number: L~ U/ G J , ~oZ62 ❑ DISAPPROVED r J eason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) Insl~~I n (D f Y\~' I 3~ r ~ f V N - r, ~n ,t' Lf f C3 Y'1 rGi t i h. t r1 E.5 11~~ , 8 2 0 I. . - ..._.ON~. ' t. 1j19 P€~. 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