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°r- `:_. PRIVATE ONSITE WASTE TREATMENT <br /> //n.'—'. ��� SYSTEMS <br /> , r�oS �; County: Burnett <br /> t1 ; s J ( POWTS) %Ito <br /> N.`" INSPECTION REPORT <br /> Safety and Buildings Division Address: �aC�- '''\- <br /> ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION c f1N_ 22.- 0Z <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(I)(m)) <br /> Permit Holder's Name: 0 City 0 Village at Town of: State Plan Transacilon ID#: <br /> l.e.o Go.coo oc..k-\anGWv ( y s <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> \OO• oo \31' oak \t-:11-h nom; \ 3508 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 1VOc'vtesCo . 100 045 Benchmark 3,L 3.46 103.46 <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 6,145 97.01 <br /> TANK SETBACK INFORMATION . St/Ht Outlet 6.5$ 96. 88 <br /> TANK TO P/L WELL BLDG I aRNTAOKE I ROAD Dt Inlet <br /> Septic >5 >9 0 >I-{ NA Dt Bottom <br /> Dosing. NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe <br /> PUMP/SIPHON INFORMATION N pc frative 7.y c1G,06 <br /> Surface <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 INFORMATION <br /> DIMENSIONS W \V L 10' _#of Cells q Type of System Distribution:Media Manufacturer: <br /> SETBACK OHWM of Nav Cony ❑ Aggregate e,2.\Z,v 3 ii <br /> P/L Bldg Well ❑ IGP ❑ Chamber <br /> INFORMATION Waters ❑ AG EZFlow Model Number: <br /> CELL TO >5 > JO S1' ❑ Mound 0 Other <br /> DISTRIBUTION SYSTEM N3 X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole SizeX Hole Observation Pipes <br /> Length Dia Length Dia Spac I Spacing ❑Yes 0 No <br /> SOIL COVER -'o Si-a6.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 ` o-ac, 9...gs1‘o\rel <br /> Filter Manufacturer:Sirn--keG <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/wiring when necessary to •e c., p eted i electrician per WI Adrnin Code.) 0 Yes 0 No <br /> Plan revision required?❑Yes 0 No \ \Z 27- Bfigrilirgdr/fill I 8� <br /> Use other side for additional information Date POWTS Inspect' ,ignature Certi'cation Number <br />