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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burrett County <br /> Visconsin <br /> ( PowrS) Property Address <br /> Department of Commerce INSPECTION REPORT /585 Do K LA Rd <br /> Safely and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Perrnd No: <br /> GENERAL INFORMATION 6-z// 57 <br /> Personal infunnation you vide ma be used for secondary1'ri Law,s. 15.04 1 m <br /> Permit Holder's Name: City 1241rown of: State Plan Transaction IDk: <br /> WO/Fe <br /> rd Teuteber Rus< <br /> CST BM Elev: Imp BM Elev: BM Description: Parcel Tax No: <br /> /00.00 1 Sdwe lilail In Rect Pint o24 3/23 01XCO <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic wj"'Le. ceiluiiii 750 a furl Benchmark "z' 97. 8 /00-OD <br /> Dosing <br /> %� 61<AW NEW Ilon Bldg.Sewer 41 064 92. <br /> Holding St/Ht Inlet 5' SIL" W. M <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L I WELL BLDG VENT To ROAD DtInlet <br /> Septic >/qp >so 3(0 — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe U <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface 7' <br /> Manufacturer Deman 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 3 1 Length go No Type of System Manufacturer: <br /> SETBACK ConVeabrona( LEACHING �Z SLOW <br /> INFORMATION P/L Bldg wall wafers In-9routd CHAMBER Model Number. <br /> CELL TO >/G»' !05' >80 Ai/ 54 /203 if <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length_ Dia Length_ Dia— Spac Spacing tZ�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: (include code discrepancies,persons present,etc.) <br /> Permit Posted? ® N <br /> Schedule 40 Vents and Observation Pipes?(Y) N <br /> Cover Material: 7X%P- <br /> Effluent Filter Manufacturer Sssr Model 6F /0 - R <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 7 O I 3 I <br /> Use other side for additional information Date POWT nspector's Signat Cert No <br />