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PRIVATE ONSITE WASTE TREATMENT <br /> SYSTEMS County: Burnett <br /> s rt <br /> ( POWTS) oZ79 Tq <br /> F'slash INSPECTION REPORT Address: G, lq V /f <br /> Safety and Buildings Division <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION <br /> Sanitary Permit No:S9//5..� <br /> 7 <br /> Personal information you provide may be used for secondary pu oses[Privacy taw,s.15.04(1 m)1 5,4111— <br /> Permit Holder's Name: 0 City 0 Village Town of: State Plan Transaction ID#: <br /> Insp BM Elev: BM Description: Parcel Tax No: 5;dlfe "LL <br /> S4•e"" /',v <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic i 65 et^ Benchmark —3,33 $" <br /> Dosing <br /> Aeration Bldg, Sewer <br /> Holding St/0 Inlet 3 L d 3 SS <br /> TANK SETBACK INFORMATION St/jI!t Outlet 3 3&0 3a9 <br /> TANK TO P/L WELL I BLDG VENTTo ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >a�'' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. S a S <br /> Holding Dist.Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative (o, 3a 90, 33 <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L I Dia I Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS 1N ,3 L 30` I #of Cells a Type of System Distribution Media M�nufactyu�� <br /> SETBACK OHWM of Nav Conv ❑ Aggregate - --„'/j ✓A �6 <br /> INFORMATION P/L Bldg Well Waters °❑ GP K Chamber Model Number: <br /> AG o EZFIow Q/ <br /> CELL TO r 7 SD` 7,?S' 7 SD ' ❑ Mound ❑ Other Qt>IC K 4 Ir I C v S <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole servation 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 Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies, persons present, etc,) Elevations taken with e Sc ,1--/Z <br /> Filter Manufacturer: oLv to <br /> Model: ..TaS. - <br /> Electrician: <br /> (Field directiv given to plumber that all electric/Wring on necessary to a completed by electrician per WI Admin Code.) ❑Yes❑No <br /> Plan revision required?❑Yes No M� A I� � I ��Lj 6_ � �2�� ] [ p 8 33 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />