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PRIVATE ONSITE WASTE TREATMENT <br /> SYSTEMS County: Burnett <br /> J <br /> ( POWTS) 3 093 Z <br /> INSPECTION REPORT 7� �r <br /> Safety and Buildings Division Address: <br /> (ATTACH TO PERMIT) <br /> Sanitary Permit.No: <br /> GENERAL INFORMATION ,(� 2 — 9-�- <br /> Personal information you provide may be used for seco7dauoses[Privac Law,s.15.04(1)(mPermit Holder's Naame: [Icity ❑ Village Town of: State Plan Transaction ID#�`�DAN•c. / /`D J�tom/.3s <br /> Insp BM Elev: SM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS H1 FS ELEV <br /> Septic j �tc,J 1000 Benchmark VD.0 <br /> Dosing c D <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/HtOutlet <br /> TANK TO P/L WELL BLDG AIR I TONTAKE ROAD Dt Inlet <br /> AIR <br /> Septic Z — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe <br /> PUMPI SIPHON INFORMATION �A/ Infiltrative 6 �• <br /> Surface �. 0 15• <br /> Manufacturer Demand Final Grade 7,s <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L I Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer, <br /> SETBACK OHWM of Nav 7- Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters ❑ IGP " -Chamber Model Number: <br /> ❑ AG ❑ EZFlow <br /> CELL TO s �,�rp' o Mound o Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipes X Hole Si �Ho Pieng g Dia Spac cing ❑Yes ❑ No <br /> SOIL COVER To ro..cl�--- <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with <br /> �• ��t� �� Filter Manufacturer: <br /> 400a `"` :M <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/wiring when necessary to be conlDleted by electrician per WI Ad min Code.) ❑Yes❑No <br /> Plan revision required?❑Yes;<No G Z/ j <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />