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r"� County <br /> a � Private Onsite Wastewater Treatment Burnett <br /> Systems ( POWTS) Inspection Report <br /> (Attach to Permit) Sanitary Permit No: <br /> Industry Services Division <br /> General Information SAN-23-248 <br /> Personal infonnation you provide may be used for secondary u oses Privacy Law,s.15.04 1 m <br /> Permit Holder's Name: U City U Village X Town of: State Plan Transaction ID#: <br /> Eric & Barbara Johnstone Trade Lake 656837 <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> Top of riser 23473 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Buildinq Air Intake Road <br /> Septic N/A <br /> Dosing N/A <br /> Aeration N/A <br /> Holding Wieser 1 2000 +2' NA +5' <br /> Pump/Siphon Information N4 Elevation Data <br /> Pump Manufacturer Pump Model Demand STATION BS HI FS ELEV <br /> Filter Manufacturer Filter Model GPM Benchmark 4.48 104.48 100 <br /> TDH Lift Friction Loss Head Total Bldg.Sewer 7.68 96.8 <br /> Forcemain Length Dia Dist.To Well Tank Inlet 7.76 96.72 <br /> Tank Outlet <br /> Dispersal Cell Information ll Dose Tank Inlet <br /> DIMENSIONS Width Length #of Cells Dose Tank Bottom <br /> SETBACK FROM Prop.Line Building Well OHWM Inst, Contour <br /> Header/Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe <br /> None Model Number: Infiltrative Surface <br /> Pretreatment Unit Final Grade <br /> Manufacturer: <br /> Model Number: <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 ❑Yes ❑No <br /> Soil Cover <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center -T Cell Edges To soil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> Holding tank for camper. No well at the time of inspection. <br /> Plan revision required? ❑Yes I@ No 11 21 2023 ,,J 1565671 <br /> Use other side for additional information. <br /> Date POWTS Inspector's Signature License Number <br /> SBD-6710(R.03/21) <br />