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PRIVATE ONSITE WASTE TREATMENT <br /> County: Burnett <br /> SYSTEMS <br /> ( POWTS) <br /> INSPECTION REPORT Address:U-38Z W L;ascAk La e,Rd <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you`provide may be used for sec ses Privacy law,s.15.04(!)(m <br /> Permit Holder's Name: ❑City LJ Village 19 Town of: State Plan Transaction ID#: <br /> CVe.t' Y.�sk �37 55 <br /> Insp SM Elev. BM Description: Parcel Tax No: <br /> 12'\ C. rA0, w; h na,� SgL4 <br /> TANK INFORMATION ELEVATION.DATA. . <br /> TYPE MANUFACTURER CAPACITY STATION B'S HI FS. ELEV <br /> Septic W ►c S e r I 0 0 0'% Benchmark —0.5 cI c\. so <br /> Dosing <br /> Aentlon Bldg.Sewer' S.0 5 9 L4. ws <br /> Holding St/Ht inlet 5.2 S q l4.2.5 <br /> TANK SETBACK INFORMATION St/Ht Outlet 5. 5 9(I.oc <br /> TANK TO P/L WELL BLDG a To ROAD Dt inlet <br /> Sep >20.>50 1> 40 NA DtBottom <br /> Dosing NA Installation <br /> Contour <br /> Aeralion NA Header/Man. S,7 . 13, gp. <br /> Holding Dist.Pipe <br /> PUMP 1 SIPHON INFORMATION fJ Infiltrative 9 2•-so <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Force main L Die Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION Z cclls <br /> DIMENSIONS W L #of Cells Type of System Distrltudlon Media Manufacturer. <br /> SETBACK OHWM of Nav X Conv o Aggregate <br /> R/L Bldg Well o IGP X Chamber <br /> INFORMATION Waters AG o EZFIow Model Number <br /> CELL TO >ZO >4 0 >So o Mound o Other <br /> DISTRIBUTION SYSTEM MA X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> _ength Dia Length Die Spac Spacing ❑Yes O No <br /> SOIL COVER no s6,% cov c r cL+ +,,m <br /> )epth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges TopsoV ❑Yes ❑No ❑Yes ❑No <br /> 'WOMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with <br /> Filter Manufacturer: o -to <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electdc/wi'ng)A(fia necessary to m eted by electrician per WI Admin Code. ❑Yes❑No <br /> 'Ian revision required?❑Yes 4 No <br /> Ise other side for additional information Date PO S ctor's Signature Certification Number <br />