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,Co JJ6c.. d?f-I Qaz:�- 2s as /?M. <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Visbonsin ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) , <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide ma be used for secondaryPri Law,s. 15.04 1 m I <br /> Permit Holler's Name: 0 City Village Tam of: State Plan Trans ion IDp: <br /> Jack (me �i s <br /> CST BM EI Insp BM Elev: BM Description: Parcel Tax No: <br /> /00. 00 SAME )VAI L 1A) a6i C?AK /2* 03 -53 a- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITYSTATION BS HI FS ELEV <br /> Septic ><22Ivy <br /> Dosing <SrAL ora Benchmark 4 z <br /> Aeration Bldg.Sewer 7S <br /> Holding `� 7 <br /> St/Ht Inlet - 5.' 9 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG "ENI TD ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic y 16 - — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. 7. 33 ?717 <br /> Holding <br /> Dist Pipe u <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Manufacturer Surface Tap 9� <br /> Demand Final Grade -- <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width 3 Length No of cols 2-- Type of System Manufacturer: <br /> SETBACK P/L BI well OHWMofNay avelr&crct� LEACHING rNFILTRr►?oQ, <br /> INFORMATION waters CHAMBER <br /> d CHAMBER Model Number. <br /> CELL TO 7 ,sp x(pp' ,t//l't� �f//A U I GK <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length O— Dia �/' <br /> SOIL COVER Length_ Dia_ Spac Spacing ❑Yes ❑No <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Ed es Topsoil ❑Yes ❑No 13 Yes ❑No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> Permit Posted? (p N <br /> Schedule 40 Vents and Observation Pipes?(y7 N <br /> Cover Material: tJ,1A <br /> Effluent Filter Manufacturer .:2CA&U. - Model A-/oo- 9 " <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No �j <br /> EF;0J 3T/I <br /> Use other side for additional information DatePO Inspector's Si ure Cert No <br />