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"T" r PRIVATE ONSITE WASTE TREATMENT <br /> SYSTEMS County: Burnett <br /> ( Powrs) 01601106 <br /> INSPECTION REPORTAddress: r Q f(•L / Q� <br /> f C <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit No: 6-9196(94 <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)1 SAY—A ^43 <br /> Permit Holder's Name: ❑City ❑ Village ® Town of: State Plan Transaction ID#: <br /> A.LAo v V&4e/f/ Jac�'saiv �C G o u.0 t v Re ut,'&v <br /> Insp BM Elev: BM Descrip"W <br /> ion: Parcel Tax No: <br /> 07- 0ia-a-yo-is-Al1-s <br /> 6,2)000 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY TATION BS HI FS ELEV <br /> Septic S FO 0 Benchmark 36 8' 03, /9 00,CIO <br /> Dosing <br /> Aeration Bldg. Sewer S'08 <br /> Holding ,8{1 Ht Inlet <br /> { g D S// <br /> TANK SETBACK INFORMATION Ht Outlet <br /> TANK TO PIL WELL BLDG VENTTO ROAD Dt Inlet A--%'' <br /> AIR INTAKE <br /> Septic 707? 7015'' I NA Dt Br :om_ <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist.Pipe 2 3 9'197 <br /> PUMP I SIPHON INFORMATION Infiltrative <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 W L #of Cells FType of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav k Conv It Aggregate �XiSfJiv� <br /> INFORMATION P!L Bldg Well Waters ❑ IGP ❑ Chamber <br /> L3 AG 11EZFIow Model Number: <br /> CELL TO ❑ Mound ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header 1 Manifold Distribution Pipe(s) X Hole Size X Hole0 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 V00 T- <br /> �,��' bp`actoo e.v7•AvLyFilter Manufacturer: L' e <br /> Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/Wring when necessary to be completed by electrician per WI Admin Code.) ❑Yes❑ No <br /> Plan revision required?❑YesWNo Lr ;a iia �/J� <br /> Y <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SBD-6710(R.4114) <br />