Laserfiche WebLink
PRIVATE ONSITE WASTE TREATMENT <br /> County: Burnett <br /> y SYSTEMS <br /> ( POWTS) d2�oOS"/ <br /> "%SIONh INSPECTION REPORT Address: <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit No:s"9yy9lo <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)] 5'4 Al—/7-S"D <br /> Permit Holder's Name: [ICity [I VillageTown of: State Plan Transaction ID#: <br /> I7 Va/reel U/ A0, �✓`OGl/51` `i%1/GOG ii/ <br /> Insp BM Elev: 7 Description: Parcel Tax No: <br /> o7-e16-a 39-/7--15-=3 <br /> 01/ 000- 0/S600 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 7eSe r Benchmark .`]$ `Q,�, S /pp,ap <br /> Dosing <br /> Aeration Bldg, Sewer S,7S 7,613 <br /> Holding St/CIE Inlet 5q <br /> TANK SETBACK INFORMATION St/Ift Outlet (Q,b / <br /> TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >/p' ?-is ' — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe , 0 9r9. <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 <br /> #of Cells I Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav # Conv ❑ Aggregate �L�G p V <br /> INFORMATION P/L Bldg Well Waters ❑ IGP ❑ Chamber Model Number, <br /> ❑ AG � EZFIow <br /> CELL TO ' 7570 ❑ Mound ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pi)e(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 renter Cell Edges Topsoil <br /> r ❑Yes e o No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with 0 S o n <br /> Filter Manufacturer: S`,'Afh e- <br /> Model: <br /> Electrician: <br /> (Field directiv given to plumber that all electric/wiring n necessa ,o be completed by electrician per WI Admin Code.) ❑Yes No <br /> Plan revision required?❑Yes No WW)7 L14 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />