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used 10-3-0 t 1 o <br /> S PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burrett County <br /> isconsjn ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT , �, (,L <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION Sr / <br /> Personal information you vide may be used for secon NsPn Law,s. 1 m W YJ <br /> Permit Holder's Name: City Vill4(1 -�O <br /> age Town of: State Plan Transaction IDM: <br /> CST BM Elev: Insp 13M Elev: BM Description: Parcel Tax Na. <br /> /00, 00 SAM>< /VA IL )u LO r4K /8. Oao 3�1-0 l <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic SXA W SOO qdficH Benchmark — /,q0 76./00 <br /> Dosing <br /> Aeration Bldg.Sewer c{ 9 36 <br /> Holding St I Ht Inlet q, q29 <br /> TANK SETBACK INFORMATION St I Ht outlet O 94, co <br /> TANK TO P/L WELL BLDG I VENT To ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic yp ;• 14, — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe IL 70 IV <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface 5&0 95.CIO <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS I Width �j Length,%.A No of calls Z- Type of System Manufacturer: <br /> SETBACK OHWMofNay j,onw/ LEACHING ADUAMC6D DRNVAGE T <br /> INFORMATION P/L Bldg Well �tWaters zh CHAMBER Model Number. <br /> CELL TO > 3'titIWCP Arw (o <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length_ Dia Length_ Dia_ Spec Spacing NrYes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Ceil Center Call Edges To loll 13 Yes EI No E3Yes ❑No <br /> COMMENTS: (Indude code discrepancies,persons present,etc.) <br /> Permit Posted? & N <br /> Schedule 40 Vents and Observation Pipes? (Y� N <br /> Cover Material: IVIA <br /> Effluent Filter Manufacturer i3esr Model (:�!F 10-s <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 3 OGt rb ? O I 3 1 <br /> Use other side for additional information Date POWTS In I s Signatu Cert No <br />