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"`T" PRIVATE ONSITE WASTE TREATMENT <br /> }psp , SYSTEMS County: Burnet <br /> ,,. -s7/ ( POWTS) _. 44t-Abex_ t <br /> i1I • <br /> -"✓'` INSPECTION REPORT <br /> Address: <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit.No: <br /> GENERAL INFORMATION Z/ —G 7 <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)] <br /> Permit Holder's Name: 0 City ❑ Village !81 Town of: State Plan Transaction IDA: <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> 7L k 1.'0.1-- z9 DD/ <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 1dle, Benchmark -3,DI /P3 O 1 <br /> Dosing <br /> Aeration Bldg.Sewer 6.s ' 9‘.5-7 <br /> Holding St/Ht Inlet 6./2- /447 <br /> TANK SETBACK INFORMATION 7 Gam_ St/Ht Outlet 1. /7 f-5-7,7-- <br /> TANK TO P/L WELL BLDG AAIRENTTO <br /> INTAKE ROAD Dt Inlet <br /> Septic NA _ Dt Bottom <br /> Dosing ' NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe <br /> PUMP/ SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer I' - • Final Grade <br /> Model Number GPM <br /> TDH Lift Friction .• ys Head TDH Ft <br /> Forcemain L Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION e. 7:_ <br /> DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ° Cony o Aggregate <br /> INFORMATION P/L ''`� �e I Waters o GP o Chamber Model Number: <br /> o EZFlow <br /> 0 o Mound o Other <br /> DI TRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distributiot -'•e(s) Hole Size • -.le ••-- vation Piles <br /> - • -.: Spacing 0 Yes ■ No <br /> SOIL COVER TD <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil 0 Yes 0 No 0 Yes 0 No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with <br /> Filter Manufacturer: <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/wiring when necessary to be completed by electrician per WI Admin Code.) 0 Yes 0 No <br /> Plan revision required?❑Yes lklo f /-7 ZI i 1- A , ?4/9 /4 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />