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Min• -a3, 04 ,'0--D <br /> ' PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> nSi- ( Powrs) Ada=as3s <br /> Department INSPECTION REPORT r <br /> Sam'aria&*Bngs en's1on (ATTACH TO PERMIT) <br /> Sanitary PJrmil No: <br /> GENERAL INFORMATION <br /> Personal infammHon you 'de my be used for sewndmy wn Privacy Law,s. 15.04(1)(m) <br /> Pam*Holder's Name: U City U Village Town of State Plan Transaction IDe: <br /> l )-5 l irec' I5 <br /> CST BM Ekw Insp BM Elev: BM Description: <br /> Parcel Tax No: <br /> /Ov.00 ,5 Bor7oti aF Sr Di, @ &d,2a,w Cc,6 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> SePtic Benchmark .10 lop./O 100.00 <br /> Dosing <br /> Atwehan Bldg.Sewer <br /> Holding WII:-6;E - '20007 6411001 St/Ht Inlet ,2 <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANK TO PA. WELL BLDG �MToo ROAD Dt Inlet <br /> AE <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding x' > 9' > zo,l 25'1. Dist Pipe <br /> PUMP I SIPHON INFORMATION InNllsh e <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain two Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Wddlh Length No of cels Tr. <br /> rype of system Manufacture <br /> /toLb*V-rlANk LEACHING <br /> INFORMATION P/L Bldg well wd Now -ra 50"s CHAMBER Model Number: <br /> Ce6esu5 K&k" <br /> CELL TO l M ubk <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_ Spec Spaclng ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cel Center Cell Edoes Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? YO N <br /> Schedule 40 Vents and Observation Pipes?(Y) N <br /> Cover Material: IJIA <br /> Effluent Filter Manufacturer n/iA Model W/A <br /> Components Not Inspected: <br /> Plan revision required?[]Yes❑No '710 [ 3 I <br /> Use other side for additional information Date PO Inspectors Sig Is Cert No <br />