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WlCj -S-as -0a— II- IIk( 3o <br /> PRIVATE ONSITE WASTE TREATMENI SYSTEMS Burnett County <br /> Visbonsin <br /> ( Powys) Pr rt r`gsAddress: <br /> Department of Commerce INSPECTION REPORT `^ — <br /> Safety and Buildings DiNsion (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION q0Personal information you provide ma be used for secondary ses Privacy Law x 15.04 1 m <br /> Permit Holder's Na / Stele Plan Transaction ID#: <br /> �e Lam' Town of: 5 <br /> CST BM lev: Ino BM Elev-. BM Desc W ion: Parcel Tax No: <br /> TANK INFORMATION ELEVATIO ATA <br /> TYPE MANU URER CAPACITY STATION BS HI FS I ELEV <br /> Septic Benchmark ,'�D d�(S <br /> Dosing <br /> Aeration Bldg.Sewer J'�v <br /> Holding St/Ht Inlet ,S <br /> TANK SETBACK INFORMATION St I Ht Outlet :Z$ <br /> TANK TO I P/L I WELL I BLDG I <br /> �TTOO ROAD Dt Inlet <br /> Septic >.16T>2125 LI 9$6 NA Dt Bottom <br /> Dosing Contour <br /> NA Installation <br /> Aeration NA Header/Man. To 30 <br /> Holding Dist.Pipe <br /> PUMP I SIPHON INFORMATION system <br /> Elevation <br /> Manufacturer Demand Final Grade Z4 4 9910 <br /> Model Number GPM —7 el) fs, <br /> TDH Lift Friction LossSystem Head TDH Ft , (, ce KV Ltn�j�'.'Qo <br /> Forcemain Length I Dia I Dist.To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width3°r Length No 01'Calls .7 ' Type of System Manuf <br /> SETBACK wen oHwM a –9 Naw LEACHING T77�4� <br /> p/L Bldg g waters CHAMBER Model Npmber, <br /> CELL TO <br /> DISTRIBUTION SYSTEM Pressure Systems Only <br /> Header/Manifolds Distribution Pipe(s) Hole Size X Hole Observation Pipes <br /> Length la 4-1 Length_ Dia_ —Spec Spacing ftYes ❑No <br /> SOIL COVER <br /> ed <br /> Depth Over �!O D Depth Over 5/ rid?` Depth of Seeded/0 Ned ❑Yes ❑No <br /> Cell Center Cell E es fTopsoil 0 Yes <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> �f 6htV 4 bLke' r fz , Com onents Not I s clad , <br /> JIr Permit Posted Cover Material <br /> OK Warning labels on manhole covers w/locks <br /> Schedule 40 Vent Material <br /> Effluent Filter installed Model `00 FR. 11 ZAybe,� <br /> Plan revision required?❑Yes❑No 0 a <br /> Use other side for additional information Date P S Inspector's Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-671 R(9101) <br />