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PRIVATE ONSITE WASTE TREATMENT <br /> 1'�1 ° County: Burnett <br /> l SYSTEMS <br /> ( POWTS) 310/7 <br /> INSPECTION REPORTn <br /> Safety and Buildings Division (ATTACH TO PERMIT) Address: dor" T oagr. <br /> GENERAL INFORMATION Sanitary Permit No: 58'868!1 <br /> Personal information you provide may be used for secondary u ses[Privacy Law,s. 15.04(1 m) S,¢y-16.-S/ <br /> Permit Holder's Name: 0 City Village Town of: State Plan Transaction IDli: <br /> i <br /> Xl'l/ e 6o.v ver Sw,'ss Gavr, kdCl <br /> Insp BM Elev: SM Description: Parcel Tax No: <br /> o P o S1Q o ti W*C� !9v� 07-a3a <br /> 40.?-i9lyoo0 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic ar sco 1040 Benchmark- <br /> Dosing <br /> Aeration Bldg.Sewef Y, 70 29.70 <br /> Holding &I Ht Inlet 4. g 1 99. <br /> TANK SETBACK INFORMATION Bt/Ht outlet <br /> kTANKTO P/L WELL BLDG AIR I TAROAD Dt Inlet ,AIR MTO?d51 7a 6" J ' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header 1 Man. <br /> Holding Dist.Pip¢ <br /> PUMP 1 SIPHON INFORMATION Infiltrative <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 L #of Cells Type of system Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ❑ Gonv c3 Aggregate <br /> INFORMATION P/L Bldg Well Waters- ❑ IGP ❑ Chamber Model Number: <br /> ❑ AG ❑ EZFlow <br /> CELL TO ❑ Mound ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems only <br /> Header I Manifold Distribution Pipe(s) :��X �Size �XHollie Observation Pipes <br /> Length Dia Length Dia Spac ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded 1 Sodded Mulched <br /> Cell Center Cell Ed es To soil ❑Yes ❑ No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Elevations taken with o 5 S To t%A.v Q <br /> 5/ T vk �sple��ra.� �ti` , Filter Manufacturer: L,',rre ]r;g <br /> -� Model: G-r <br /> Electrician: <br /> (Field directivegivento plumber that all electridwiring when n ssary to be c plated by electrician,per WI Admin Code.) ❑Yes B-No <br /> Plan revision required?❑Yes®No �Z J(n o�a683J' <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SBD-6710(R.4114) <br />