Laserfiche WebLink
PRIVATE ONSITE WASTE TREATMENT <br /> SYSTEMS County: Burnett• '"�� � <br /> h <br /> ° a Safety and Buildings Division INSPECTION REPORT(ATTACH TO PER-MIT) Address: c Foy. yca�� <br /> Sanitary Permit No: <br /> GENERAL INFORMATION S A IV -21 - 19 3 <br /> Personal information you provide may be used for second ses PrivacylAw,s.15.04(1)(m <br /> Penult Holder's Name: 0 City Village Town of: State Plan Transaction ID* <br /> Sol\n �)or► ��c-�ec\ 7 S w;S.S 6 3? 630 <br /> Insp BM Elev. BM Description: Parcel-Tax No: <br /> o OL <br /> TANK INFORMATION ELEVATION:DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS M FS ELEV <br /> Septic P Sn ;l�cako� 106dg Benchmark — �. y2 99. 59 <br /> Dosing <br /> Aeration Bldg.Sewer` , 8 6 9 N. ,2z <br /> Holding St/Ht Inlet 5.52 93. (o6 <br /> TANK SETBACK INFORMATION St/Ht Outlet 6.)3 93. 40 <br /> TANK TO P/L WELL BLDG 0WTO <br /> 11A ROAD Dt Inlet <br /> Septic >15 a Z O NA Dt Bottom <br /> Dosing NA Installation <br /> COMM <br /> Aeration NA header/Man. <br /> Holding Dist,Pipe <br /> PUMP/SIPHON INFORMATION NA lnfiitratiVe '>. o q 2.58 <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L, Die Dist.To Well Top;of lid <br /> DISPERSAL CELL INFORMATION 1 cel 1 <br /> (DIMENSIONS W L #of Cells Type of System DistrlhutiortMedla Manufacturer: <br /> SETBACK OHWM of Nav Conv ❑ Aggregate <br /> P/L Bldg Well ❑ IGP ❑ Chamber <br /> INFORMATION Waters ❑ AG )( EZFIow Model Number. <br /> CELL TO > IS ?20 a Mound a other <br /> DISTRIBUTION SYSTEM NA X Pressure Systems Only <br /> header/Manifold ` Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> .ength Die Length Dia Spec Spacing 0 Yes ❑ No <br /> 301LCOVER no soil Bove c- a -)r;me, o ins � 'an <br /> )epth Over Depth Over Depth of Seeded/Sodded Mulched <br /> :ell Center Cell Edges To soil 0 Yes ❑No 0 Yes 0 No <br /> :OMMENTS; (Include code discrepancies, persons present,etc.) Elevations taken with <br /> Filter Manufacturer: <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/w'ring when necessary tq 0 completed by electrician per W I Ad�min Code.) ❑Yes 0 No <br /> Ian revision required?0 Yes 0 No 7 1116)77 )-5 <br /> se other side for additional information Date POWTS*10l's Signature Certification Number <br />