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s � j 6 —9 -I 3 ;�3a -16 <br /> 14sconsin <br /> P IVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> c Powrs� -783�: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) v <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you proviAe may be used for secondary pu Privacy Law,s.15.04(1)(m) <br /> Perr01) olders ame: State Plan Transaction ID#: <br /> J � Town of: j <br /> CST BKA Elev: I Inhp BM Elev: BM Description: Parcel Tax No: <br /> /CV. pp 6AMIf -1P of 5IO LK. 01 - -6 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 0p-we5G0 /O 0 O Benchmark /,5 /C) "50 l UO.00 <br /> Dosing <br /> Aeration Bldg.Sewer z/. SS % 99/05 <br /> Holding St/Ht Inlet Z 07 91. 4-3 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG AAIR R I TNTAAKE ROAD Dt Inlet <br /> Septic >25, S& — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe �,6p7 94 03 <br /> PUMP 1 SIPHON INFORMATION System <br /> Elevation 7 50 9J4 00 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> Lift Fr.Loss Head TDH <br /> Forcemain Length Dia DistlWell <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width &,' Length 3 No of Cells z Type of System Manufacturer: <br /> SETBACK OHWM of Nav C M*s(ienal LEACHING <br /> INFORMATION P/L Bldg well waters ?n"9^iwd CHAMBER Model Number: <br /> CELL TO 51+- x 4D' IS/ 5 <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipe <br /> Length Dia Length ±1D Dia `( Spec — Spacing NrYes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges I Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Components Not Inspected <br /> air Permit Posted Cover Material 'T_- R, <br /> a- Warning labels on manhole covers w/locks <br /> dr- Schedule 40 Vent Material <br /> or- Effluent Filter installed Model A-1FR. <br /> Plan revision required?❑Yes❑No I Ot F 7 0 I 3 I <br /> Use other side for additional information Date POWP Inspector's Sig a re Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R(3101) <br />