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11ps , 3o <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burrett County <br /> Wisconsin ( POWTS) Property Address:aS)L- <br /> Department of Commerce INSPECTION REPORT <br /> SeAsty and Buildings Division (ATTACH TO PERMIT) <br /> Sandary Permit No-.' <br /> GENERAL INFORMATION 5qC) aq <br /> Personal information you provide ma be used for recon Pri Law,s. 15.64(1 m) <br /> Permit Holder's Name: ity Vllage Town d: State Plan Transaction ID#: <br /> ba r'0 0 1 est MarshlDocl >, A"'C4) <br /> CST BM Elew Insp BM Elev: BM Description: Parcel Tax No: <br /> /r0rwt Vdrl In Pur* Pot, o7oYo•zw-0 2 <br /> , 0 <br /> of - DOt) <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic >, L1a�edra/s 750 Gr({�1, Benchmark 6 20 106.,z0 10a co <br /> Dosing <br /> Aeration Bldg.Sewere p 7.35 9.q 55 <br /> Holding St I Ht Inlet 7.410 91.71 <br /> TANK SETBACK INFORMATION St I Ht outlet <br /> TANK TO PIL WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >100' >60' 18' + NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist Pipe 7.66 9S.60 <br /> PUMP I SIPHON INFORMATION Surma 97 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Fofcemain Length Dia I asL To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width Length No of Celt Type of System Manufacturer: <br /> SETBACK ContxH4aral LEACHING % )Loo <br /> INFORMATION P/L Bldg wee wateB dNav� „'� CHAMBER Model Number. <br /> CELL TO >w >ISCSIir() 1 >70' — 6-Z /203 H <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipes) X Hole Size X Hole Observation Pipes <br /> Length_ Dia Length_ Dia_ Spec <br /> Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cetl Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Ore: 9 Dratl,Field 1'6wgs 5o/wAro.,. Fy'aw a <br /> Permit Posted? VN ?ONG e� JdEwa6raw cis raUa, out s F <br /> Schedule 40 Vents and Observation Pipes? 0 N <br /> Cover Material: 'Ty/AII'_ <br /> Effluent Filter Manufacturer .BEST Model 6; $ <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No Jr ' 2A1� 77 b I ,5 I <br /> Use other side for additional information Date PO Inspector's Signa / Cert No <br />