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PRIVATE ONSITE WASTE TREATMENT <br /> SYSTEMS County: Burnett <br /> Ps ( POWTS) <br /> " = INSPECTION REPORT Address:11,16 /fokrys Rd. <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION $-eM7 <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(t Xm)] S - s- <br /> Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: <br /> ie,'C- a✓d a�/iL°�s —v Sa7� Goo^ Aj w <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> o7- -�O-IV-a9- <br /> v(7o 5 0 5-DD S– 0/Bo Do <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark /OO,o0 <br /> Dosing 7 <br /> Aeration Bldg. Sewer (p 2 <br /> Holding G In IC 1011900 a 719AJ 'S 1 Ht Inlet (p 3 9�,/ <br /> TANK SETBACK INFORMATION ,X/Ht Outlet 7 /7 96-. 7 <br /> TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> ^^ / <br /> AIR INTAKE 7, a Cp 9s Sg <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding 1716 Dist. Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH LiftnFriction Sys Head TDH Ft <br /> Forcemain Dia I Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells F Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ❑ Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters 11G❑ Chamber Model Number: <br /> El ❑ EZFlow <br /> CELL TO ❑ Mound ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems only <br /> Header/Manifold Distribution Pipes) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing ❑Yes ❑ No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil Q Yes ❑ No ❑Yes 11No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Elevations taken with G✓a P ozin <br /> a- /noo 641 -rANKS For KvIvre Pow& Filter Manufacturer: — <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/wiring when necessary to a completed by electrician per WI Admin Code.) ❑Yes❑ No <br /> Plan revision required?❑ Yes 0 No g 3/ <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> CRn_r7ln/R All dl <br />