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ti <br /> PRIVATE ONSITE WASTE TREATMENT <br /> Al > <br /> r� SYSTEMS County: Burnett <br /> ( POWTS1 <br /> and <br /> INSPECTION REPORT <br /> Safety and Buildings Division Address: <br /> (ATTACH TO PERMIT) <br /> Sanitary Permit.No: <br /> GENERAL INFORMATION Personal information you provide may be used for secondary urposes[PrivacyLaw,s.15.04(1 X SAN - 2.1 - 207 <br /> m)] <br /> Permit Holder'sCN�ame:: 7 t7 City El Village W Town of: State Plan Transaction ID#: <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> A 8 " oak l 144 p7 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> L <br /> A w - g C7e Benchmarkn Bldg.Sewer <br /> St/Ht inlet <br /> TANK SETBACK INFORMATION JS St/Ht Outlet <br /> TANK TO P/L WELL BLDG R INTAKE <br /> VENTTo ROAD Dt Inlet <br /> AI <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration INA Header/Man. <br /> Holding IDist.Pipe <br /> PUMP SIPHON INFORMATION Infiltrative b. w� 9;3•�3 <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH rictio oss ead jTDH FtF main Dia Dist.To Top of lid <br /> D13PRSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells Type of System Distributions Media Manufacturer.- <br /> SETBACK OHWM of Nav Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters o IG j Chamber Model Number; <br /> o AG ❑ EZFIow <br /> CELLTO 7— 7sb' ❑ Mound o Other <br /> DISTRIBUTION SYSTEM X Pressure Systems only <br /> Header/Manifold I Distribution Pipes) X Hole Size X Hole bservation Pi es <br /> a pac pacing es No <br /> SOIL COVER A n Qd4-t cot <br /> Depth Over Depth Over Depth o Seeded/Sodded Mulched <br /> Cell Center Cell Edges To soil O Yes ❑No 1-0 Yes ❑No <br /> COMMENTS; (Include code discrepancies, persons present,etc.) Elevations taken with <br /> Filter Manufacturer: /•re 7,'.+► cx�* <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/wiring when necessary tq,4e com ted by electrician per WI Admin Code.) ❑Yes❑No <br /> 'Ian revision required?D Yes❑No <br /> )se other side for additional information Date POWT ect is Signature Certification Number <br />