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-J(Wrs, )a ; oo <br /> VisconsiBurnettPRIVATE ONSITE WASTE TREATMENT SYSTEMCounty <br /> n ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Brew ana Buildings D� (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide my be used for aecon Pn Law,s. 15.04(i m)IJ�D3 <br /> Permit H <br /> o <br /> l <br /> d <br /> ers 0 city village Town of: State Plan Trannsachon IDB: <br /> VO IECST BM Elelea E M Description: I w"h'�/ ALV rein <br /> Parcel Tax No: <br /> morn Sfdrrrq @ INIJ Cnrher o7-c�zz-3v�e-za-� <br /> TANK INFORMATION 03-�-oiivov <br /> ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark r/p /02,y0 lam, <br /> Dosing <br /> Aeration Bldg.Sewer&,b' G. <br /> Holding 96.0 <br /> U FFGuT1 Coa6,s6w 12 a�U 7SU= w St I Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO PIL WELL BLDG VENT TO TAKE ROAD DtInlet <br /> Sepfic NA Dt Bottom JO, TS <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding >50' 0 *' I 20 >,Z,5, x zo' Dist Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufaolurer Demand Final Grade <br /> Model Number GPM <br /> TDH LiftFriction toss System Head TDH Ft <br /> Forcernalin Length I Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> :DIMENSIONS Width Length No of cels Type of System Manufacturer. <br /> SETBACKoHwrdorrlav '�Vlece. Brit LEACHING <br /> INFORMATION P/L Bldg wen weds CHAMBER Model Number <br /> CELL TO ianfc <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipes) X Hole Size X Hole Observation Pipes <br /> Length_ Dia_ Length_ Dia_ Spec_ Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Ed es Topsoil ❑Yes ❑No []Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> NorE, lkfcuTT /256/756 sr//c ia»K vsat as a lddag <br /> Permit Posted? © N %aac, rise Yo Qv� -ro wet- a rndrrndwl sit d-SgryI <br /> Schedule 40 Vents and Observation Pipes?( N Iebeftfri&re De6eY rae4;n Mou4 m &� j b;6wa.// <br /> Cover Material: AvIA u�i <br /> Effluent Filter Manufacturer NIA Model A//4 <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 2010 <br /> I I <br /> Use other side for additional information Date POWT Inspectors Signat Cert No <br />