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`T 0S , Oq r -� <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> A&COnsin ( POWTS) Property Address:(7 90 1 <br /> Department of Commerce INSPECTION REPORT r. <br /> Sarety and Buildings Division (ATTACH TO PERMIT) Sanitary Pahnit No: <br /> GENERAL INFORMATION qg(a 3 <br /> Personal information you provide my be used for secondary I Prii Law,s.15.04(1 m <br /> Permit Holders Name: LiCity U Village of: State Plan Transaction I13P <br /> M I b <br /> CST BM Elev: Insp BM EI BM Description: Parcel Tax No: <br /> W.C-0 SAMI' AIL ,A) OWC 04K 30`' bl&3 I -0 - <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE I MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic '7750 6�q-an) Benchmark /o 0 /cc. co <br /> Dosing C"om6m4'64 " 5C;70 A[toJ <br /> Aeration Bldg.Sewer <br /> Holding St l Ht Inlet pp 6660 <br /> TANK SETBACK INFORMATION St I Ht Outlet 40 <br /> TANK TO I P/L I WELL I BLDG I �IMAKE ROAD Dt Inlet <br /> Septic NA Dt Bottom 11.51 92.09 1 <br /> Installation <br /> Dosing j NA Contour <br /> Aeration NA Header/Man. 4, 98.75 <br /> Holding Dist Pipe 485 98. 75 <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> surface o 5 <br /> Manufacturer /TTAe 1AA)-r &3arwDemand Final Grade <br /> Model Number 9 g I.I � GPM <br /> TDH Lift`,? Friction Loss 1,17_ System Head jZ,5 TDH /I.I Ft <br /> Facemain Length jam' Dia,T Dist To Well > 46' <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS WIM 'yLengthNo of cess 1 Type of System Manufacturer. <br /> LEACHING <br /> SETBACKwaters of Nav oU1JD it)/ CHAMBER Model Number. <br /> INFORMATION P/L Bldg well <br /> CELL TO > 50 x 5s' /CO' d/A /.mrr-&�;'l <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distritwtion,Ppe(s) X Hole Sin X Hole Observation Pipes <br /> Length-S Dia )rry Length Dia Spac 3.� ./g$ Spacing g' Q Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center /.0 Cell Edges oso'+ Topsoil xlo" ®'Yes ❑No m Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? i2) N <br /> Schedule 40 Vents and Observation Pipes?® N <br /> Cover Material: T1✓PAk. <br /> Effluent Filter Manufacturer �A�L. ModelAA- 1�8 __ <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No )� �� rpt 7 <br /> Use other side for additional information DateOWr nspector's fStgire Cert No <br />