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Nvi�/�/� PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> sconsin ( Powrs) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buikhngs Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide my be used for=ondary puses Pri law,s. 15.04(1 m <br /> Permit Holders Name: City village Town of: State Plan Transaction IDA: <br /> CST BM Elev: Imp BM Elev: BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St I Ht Inlet <br /> TANK SETBACK INFORMATION St l Ht Outlet <br /> TANK TO PIL WELL BLDG IVENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist tripe <br /> Infiltratve <br /> PUMP I SIPHON INFORMATION Surface <br /> Surface <br /> Manufacturer 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 Length No of Cells Type of System Manufacturer: <br /> LEACHING <br /> INWS <br /> SETBACK <br /> P f L Bldg w aN� CHAMBER Model Number. <br /> CELL To <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length_ Dia Length_ Dia_ Spec Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Indude code discrepancies,persons present,etc.) <br /> Permit Posted? Y N <br /> Schedule 40 Vents and Observation Pipes? Y N <br /> Cover Material: <br /> Effluent Filter Manufacturer Model <br /> Components Not Inspected: <br /> Plan revision required?[]Yes❑No <br /> Use other side for additional information��Date POWTS Inspector's Signature Cert No <br />