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PRIVATE ONSITE WASTE TREATMENT <br /> County: Burnett <br /> SYSTEMS <br /> 3 <br /> m ( POWTS) 976 S <br /> INSPECTION REPORT Address: Ga.fy <br /> Safety and Buildings Division (ATTACH TO PERMIT) T <br /> GENERAL INFORMATION I Sanitary Permit No:'Ter?9/ <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(1 Xm) ,JAN- //°—/8 7 <br /> Permit Holder's Name: ❑City LJ Village Town of: State Plan Transaction ID#: <br /> V rgiL AjorkLa�.At/ Gi%✓ca LN Goyn yy /�f�if w <br /> Insp SM Elev: BM Description: Parcel Tax No: <br /> °f �ak,,,e jk Y4a /8"A6ov e 6rao(� , 67-o,16-.9-'39-/7-33-3 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic lvoeweSt,o Benchmark — 9� /40 <br /> Dosing <br /> Aeration Bldg.Sewer a, a'-) 6 <br /> Holding js/Ht Inlet .3, ?6,31 <br /> TANK SETBACK INFORMATION /Ht Outlet �, . 16 <br /> TANK TO P/L :*ELL BLDG VENTTO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic 7s-d 7 XT' 7 f NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header 1.-MM, <br /> Holding Dist.Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells F Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ❑ Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters ❑ IGP o Chamber Model Number: <br /> ❑ AG o EZFlow <br /> CELL TO ❑ Mound ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded!Sodded Mulched <br /> Cell Center Cell Edges Tosoil es ❑No No <br /> COMMENTS: (Include code discrepancies,persons present, etc.) Elevations taken with WAlle f o L ro. <br /> Filter Manufacturer: S;,y eo <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electrictwiring when necessary to be completed by electrician per WI Admin Code.) ❑ ❑ NO <br /> Plan revision required?❑Yes 10 No 4� I � , �,, 22, 6$3 3 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SBD-6710(R.4/14) <br />