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`sanT UF` <br /> � County <br /> Private Onsite Wastewater Treatment <br /> Burnett <br /> Systems ( POWTS) Inspection Report <br /> (Attach to Permit) <br /> Sanitary Permit No: <br /> Industry Services Division <br /> General Information SAN-24-259 <br /> Personal information you provide may be used for secondary purposes Privacy Law,s. 15.04 1 m <br /> Permit Holder's Name: Ij City Lj Village x Town of: State Plan Transaction ID#: <br /> LuAnn Brey / Doering Cottage LLC Scott 662115 <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> 100' Riser of filter 18013 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road <br /> Septic x i S-K n N/A <br /> Dosing N/A <br /> Aeration N/A <br /> Holding Skaw 1200/750 1 >2' 1 >25' 1 >5' <br /> Pump/Siphon Information NA Elevation Data <br /> Pump Manufacturer Pump Model Demand STATION BS HI FS ELEV <br /> Filter Manufacturer Filter Model GPM Benchmark 2.26 102.26 100 <br /> TDH Lift Friction Loss Head Total Bldg.Sewer <br /> Forcemain Length Dia Dist.To Well Tank Inlet New=5.10 97.16 <br /> Tank Outlet Old=3.80 98.46 <br /> Dispersal Cell Information/v A 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 NA Final Grade <br /> Manufacturer: Riser Filter 2.26 100.00 <br /> Model Number: <br /> Distribution System N A X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing TO Yes ❑No <br /> Soil Cover <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> MUAYI-.d ,I� Yvom <br /> Plan revision required? ❑Yes kfNo 10 21 2024Wrl11,U 151�5Co—] <br /> Use other side for additional information. <br /> Date POWTS Inspector's Signature License Number <br /> SBD-6710(R.03/21) <br />