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T"; PRIVATE ONSITE WASTE TREATMENT County: Burnett <br /> 4: 1 <br /> SYSTEMS <br /> >�, . 1 ( POWTS) <br /> '� INSPECTION REPORT Address: NA <br /> - <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION .11/— l'"'l 2 7 <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)] �7 3 <br /> Permit Hol er's Name: ❑City 0 Village Town of: State Plan Transaction ID#: <br /> �Vc , I�, ✓1 Sw ; S <br /> lnsp BM Mew: BM Description: Parcel Tax No: <br /> • ) Ov NGt ; 1 171 if fi5 e V c).P60 R <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Of v✓e5 Co - V)00 Benchmark 2.7 1o27 I° 0 <br /> Dosing <br /> Aeration Bldg.Sewer Li. 7 <br /> Holding St/Ht Inlet 4.--ie 977,2 <br /> TANK SETBACK INFORMATION . St/Ht Outlet 4.11 91.73 <br /> TANK TO P/L WELL BLDG ANTT°KE ROAD Dt Inlet <br /> AIR INTA <br /> Septic t -t&) 1I/16' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe <br /> Infiltrative 5.03 9/ PPUMP/ SIPHON INFORMATION Surfacet� <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L Dia Dist.To Well Top of lid <br /> DISPERSAL CELL L INFORMATION <br /> DIMENSIONS W 3i L 90 #of Cells Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nay Conv o Aggregate <br /> INFORMATION P/L Bldg Well Waters o IGF o Chamber Model Number: <br /> ❑ AG g/ EZFIow <br /> CELL TO t 5 -} I 0 ijt i'r-� ("k ❑ Mound o Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> _ength Dia Length Dia Spac Spacing 0 Yes 0 No <br /> SOIL COVER IoY1 e <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil 0 Yes 0 No 0 Yes 0 No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with VictJe RiAf5 6 ivo <br /> Filter Manufacturer: <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/whin• -n ne essay%�b-:completed by electrician per WI Admin Code.) ❑Yes 0 No <br /> i <br /> 'Ian revision required?❑Yes❑No 1 I )7 ) 5;7723 <br /> a,r 's - / !,1 • <br /> Ise other side for additional information Date POWT:, spector's Signature Certification Number <br />