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PRIVATE ONSITE WASTE TREATMENT <br /> County: Burnett <br /> SYSTEMS <br /> a <_; ( POWTS) <br /> -35-70 <br /> INSPECTION REPORT Address:/��f T��L ]f' <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit No: <br /> Personal information you provide may be used for secondary purposes I Privacy Law,s. 15.04(1)(m)] <br /> Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: <br /> ac�o� �Lls OLorooxv G0vrt,f y �lvitw <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> � / / o7-0i2-2- <br /> Z> -0`� A/4iG ,-w e?r 4f15s-,07OC60 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITYSTATION BS HI FS ELEV <br /> Septic -r v11141,IrA loe /0 SO Benchmark — 09 Q 9. 1 /,0,0,00 <br /> Dosing <br /> Aeration Bldg. Sewer I- Wo 97,4 <br /> Holding St I Of Inlet 1 . $$ 7. ;.a, <br /> TANK SETBACK INFORMATION St/HCOutlet a�� 96, <br /> TANK TO P/L WELL I BLDG I VAIR INTAENTTA KE ROAD Dt Inlet <br /> eptic a.C7 6 O a NA NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man, <br /> Holding Dist.Pipe ,!0 S.0 <br /> PUMP/SIPHON INFORMATION Infiltrative s.10 -00 <br /> Surface l e b r o a o <br /> Manufacturer Demand Final Grade <br /> Model Number <br /> GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain LDia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W 3 ' L I g0' #of Cells 3 Type of system Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav Conv ❑ Aggregate j;V.;ZTr4 Aw <br /> INFORMATION P/L Bldg Well Waters ❑ IGP A Chamber Model Number: <br /> ❑ AG ❑ EZFIow <br /> cELLTO ❑ Mound ❑ Other Ov;ek ys �l�s <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length_ Dia Spac Spacing es ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center '- Cell Edges Topsoil n Yes of nl„ IGO IGIv0 '21 N <br /> u u <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with -oh r <br /> ilter Manufacturer: %`me <br /> Model: e.7' Ye <br /> Electrician: [ <br /> (Field directive given to plumber that all electric/wring when necessary to be completed by electrician per WI Admin Code.) ®Yes❑No <br /> Plan revision required?[] Yes ;YNo 1 I 1 j_S 13 S 3 5 <br /> Use other side for additional information Date P S Inspector's Signature Certification Number <br /> SBD-6710(R.4/14) <br />