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Wi'' PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> sconsin ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT vo -ra; <br /> safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide may be used for secondary Privacy Law,s. 15.04(1 m)] Z4S61 <br /> Permit Holder's Name: City LJ Village Town of: State Plan Transaction ID#: <br /> CST B Elev: In BM Elev: BM Description: Parcel Tax No: <br /> 100. Gb 6i4ME NAIL IN R&b DAK If- O S-OS <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE 7 MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic kr-40 800-A/10MA, /455c7 VT44 Benchmark —/OZ /Co.DO <br /> Dosing <br /> Aeration 7$ <br /> 98.15 <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANK TO P/L WELL FBLDG aMNTonly: ROAD Dt Inlet <br /> Septic 25;t 40'r K' _ NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe 9.3393.1wa0 <br /> PUMP/SIPHON INFORMATION Infiltrative iu,& 92 A <br /> Surface 9.i? <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width 31 Length&Z_g No of cells Z Type of System Manufacturer: <br /> SETBACK P/L BldgwOHWM of Nav Cortverrtbnw.4 LEACHING ll?f�O I FFU 56� <br /> INFORMATION en WatersTit_-9 CHAMBER Model Number. <br /> CELL TO .� 'f !a0'f >/od — STAMDAQ.O I I" <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 Spacing es ❑No <br /> SOIL COVER <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.) <br /> Permit Posted? ® N <br /> Schedule 40 Vents and Observation Pipes?(Y N <br /> Cover Material: AIIA <br /> Effluent Filter Manufacturer_ XAw- Model h -(oo <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No <br /> Use other side for additional information Date 4PO4Spectors;-Sqjgna& Cert No <br />