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" PRIVATE ONSITE WASTE TREATMENT <br /> Fs. County: Burnett <br /> y; II► SYSTEMS <br /> POWTS <br /> INSPECTION REPORT Address: Petrol✓A, X/- <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 6'Q476 <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(t xm)] A.V-/s- 9� <br /> Permit Holder's Name: City Village Town of: State Plan Transaction ID#: <br /> 32 At-e f 949AA, '{ (,{l /So+V �iL/ipN Cow—oc' /FC✓:(w <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> o-1-,6X-J-ya-/7-iy-3 <br /> 000-o//000 <br /> /il/�+%�< •�Nt /rl C <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 1jW-300 60*1 d Benchmark , 30 /4A,30 /00,06 <br /> Dosing <br /> Aeration Bldg.Sewer 7 1/7 '7o?-93 <br /> Holding St/Wlnlet 7, S'3 ?d-77 <br /> TANK SETBACK INFORMATION St I Outlet -7.97 902.Y3 <br /> TANK TO P!L WELL BLDG AIR I NTATA KE ROAD Dt Inlet <br /> AIR I <br /> Septic 'ft o _ /S NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe , 01! 9101 <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface g .�S 9/,5:5, <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L Dia I Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W 31 L /30' #of Cells F Type of System Distnbution Media Manufacturer: <br /> SETBACK OHWM of Nav J. Conv in Aggregate f'NA Aeo fors <br /> INFORMATION P/L Bldg Well Waters ° G K Chamber Model Number: <br /> ❑ <br /> ❑ EZFIow <br /> CELL TO ,2 S' 30� — ❑ Mound ❑ Other Qo„ Y <br /> DISTRIBUTION SYSTEM x Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole ObservationPipes <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 Kf* -01 eL � CvfY 7-acKSo4, <br /> Filter Manufacturer: <br /> Model: EP to <br /> Electrician: <br /> (Field directive given to plumber that all electriclwiring when n cessary to be completed by electrician per Wl Admin Code.) ElYes❑No <br /> Plan revision required?[]YestNo a( "� Z� k 11 a a� 3 <br /> 3 1 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> 1Zan_a71n rR eiidi <br />