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Visconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( PO rS) Property Addms: <br /> Department of commerce INSPECTION REPORT %34 N Ir 0 <br /> Safety mid&elm"de D1ASO" (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 3�O��f <br /> Pcmnal info tioo you ' my be used for sewn PrivacyLew,s. 15.04(1 m <br /> Permit Holder's Name: City Village orm d: State Plan Transaction IDk: <br /> kwfle �l�t<a ti, "i Js 6'.tr f6e.0 <br /> CST BM Elev: Insp BM Elav: BM Description: Parcel Tax No: <br /> /Co•OJ Sdt^+C $W Corner o F Gi ,/� 07•ao6 2-Sd'r/-21-5 <br /> v49c - �rfTO+IOF 510.ub o5-po/-o/pJG1� <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> KA W /000 Ga,/(s.L Benchmark 3.1(0 A73./6 /b5;6 00 <br /> Dosing <br /> Aeration Bldg.Sewer jF¢ 5. /6 <br /> Holding St/Ht Inlet ,, <br /> TANK SETBACK INFORMATION St/Ht Outlet 5.54 97 fi2 <br /> TANK TO PIL WELL BLDG VENT <br /> TAOxE ROAD Dt Inlet <br /> AR Septic NA DtBottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number <br /> GPM dew s+b*.+b' <br /> MH Lift Friction Loss System Head TDH R <br /> Forcemain length Dia Dist To Well <br /> DISPERSAL CELL INFORMATION - S%er spm 9osyo <br /> DIMENSIONS Width /Q. Length 2* 1 NoofCads 1 Type of System Manufacturer. <br /> SETBACKLCHING <br /> INFORMATION P/L Bldg well waWM of Nay CH4AMBER <br /> {�YaGeena.b Model Number. <br /> CELL TO I Io> <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size I X Hole Observation Pipes <br /> Length_ Dia Length_ Dia— Spac I Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> CeN Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? O N <br /> Schedule 40 Vents and Observation Pipes? (Y—) N <br /> Cover Material: A114 <br /> Effluent Filter Manufacturer '-<�.46z5w- Model h-/00-/Z <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 2o1f 70 1 f I <br /> Use other side for additional information Date POWTS Inspector's Signature Cert No <br />