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`�' E ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> sCOnsin ,, / ( POWTS) Property Address: <br /> Department of Commerce. d(�- INSPECTION REPORT <br /> Safety and Buildings Division U (ATTACH TO PERMIT) S <br /> GENERAL INFORMATION Sanitary Permit No:' i <br /> Personal information you provide may be used for secondary f Privacy Law,s.15.04 1 m <br /> Permit Holders NaState Plan Transaction ID#-. <br /> Town of <br /> CST BM Ele Insp BM Eley: BM Description: Parcel T N0: <br /> /Gtr 58ME NAIL leu Rc0 D,��, .Z0" 01 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic ,46J O Benchmark 3.75 /o3. 76 /Go.co <br /> Dosing <br /> Aeration Bldg.Sewer 3, 99. 9 <br /> Holding St/Ht Inlet i 99. 59 <br /> TANK SETBACK INFORMATION St/Ht Outlet 4• 97- 39 <br /> TANK TO P/L WELL BLDG VENT To a ROAD Dt Inlet <br /> Septic (,'s >, lfj — NA DtBottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe 7, 67 ,8 <br /> PUMP/SIPHON INFORMATION System <br /> Elevation i 18.7p9 .D3 <br /> Manufacturer Demand Final Grade <br /> Model Number GPMIJ,ss . „zt z 127 96.49 <br /> Lift Fr.Loss Head TDH Eo z B. /O /o <br /> Forcemain Length Dia Dist/Well D,yE, P 3 7 / 7 96.58 <br /> DISPERSAL CELL INFORMATION .5ywm EL, A.vo 9,5.75 <br /> DIMENSIONS 1Wldth(p Length3o'3 Noodf Type of System Manufacturer: <br /> SETBACK 12.6 oHWMorNov e0Ave r6Iw0l LEACHING <br /> INFORMATION P/L Bldg well wee 1fl- CHAMBER <br /> yroww(, Madel Number: <br /> CELLTO g` Y7f' /D >So 9$ 'r <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) �Hole Size X Hole Observation Pipes <br /> Length — Dia Length�'� Dia " Spec — Spacing [S'9es ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> AW LA)e c- -ro 8E /sj sr*jW Components Not Inspected <br /> t' Permit Posted Cover Material -TYPR2. <br /> ar- Warning labels on manhole covers w/locks <br /> Ir Schedule 40 Vent Material <br /> di/�Effluent Filter installed Model A-18v0 6 <br /> Plan revision required?❑Yes❑No /D 1 /o 1 03 1 1 7 0 1 3 I <br /> Use other side for additional information Date POWT nspector's Signatur Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R 1) <br />