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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Vis onsin ( Pow S) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION b <br /> Personal information you provide may be used for secondwy ses f Privacy Law,s. 15.04 1 m <br /> Permit H is Name: � )II /S'�tatate Plan/Transaction ID#: <br /> U� .� Town of: �l �l `7 <br /> / 3/ <br /> CST BM Elev: Insp BM Elev: BM DM Parte Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic a Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer $ <br /> Holding St/Ht Inlet 3� <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG ENT TO ROAD Dt Inlet <br /> INTKE <br /> Septic 5 Ll NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. y 3 <br /> Holding Dist.Pipe S jtp <br /> PUMP/SIPHON INFORMATION System eD <br /> Elevation <br /> Manufacturer Demand Final Grade <br /> Model Number GPM -O 3 <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist.To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width3?qj Length o of Calls c2, TypeofSystem Manufacturer: <br /> SETBACK P/L BI well OHWM CHAMBER <br /> of Nov Fi -LEACHING h � <br /> INFORMATION waters Model Number. <br /> CELLTO �� l Cd1S /rq n51� <br /> DISTRIBUTION SYSTEM 2 1 9 X Pressure Systems Only <br /> Header/Manifold Distribution fx X Hole Size X Hole Observation Pipes <br /> Length Dia e i Length_ Dia_ Spac Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over ' 3D0— Dep hCell N <br /> Over � � Depth of Seeded/Sodded ❑ Mulched❑No <br /> Cell enter _ <br /> C ENTS: ude cod pantti s,persons present,etc.) .9Y5fe^ — �. i)d V _ <br /> Components Not Inspected <br /> Permit Posted Cover Material ' ` ' Va ( r�S'7a/lQ 46,4j o <br /> Warning labels on manhole covers w/locks k'y'n"'�' ` G17 6 <br /> Schedule 40 Vent Material 4 "`jac K7 1f �h01-' <br /> '575—Effluent Filter installed Model D MFR. <br /> Plan revision required?❑Yes` No 3 7 - - <br /> Q <br /> Use other side for additional information Date WTS Inspectors Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,IM 53701-7302 SBD-6710 R(3101) <br />