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PRIV TE ONSITE WAS Burnett County <br /> SCOnsin l; Powis) P � A R <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Bulldinp Division /�'/ (ATTACH TO PERMIT) Be <br /> t/ft I/�j o;-l d Q a— Sanitary Permit No: <br /> GENERAL INFORMATION ' <br /> rm <br /> Personal infoation you m be used for recon / es Pr' Law,s. 15.04 l m / <br /> Permit Holder Name: Isar SOh f) State Plan Transaction ID#: <br /> sM Town of: <br /> CST BM Rev: I Insp BM Elev: BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark 3� OS 6v <br /> Dosing L <br /> Aeration Bldg.Sewer <br /> Holding St/Ht inlet fl <br /> TANK SETBACK INFORMATION St/Ht Outlet (,)' .00 <br /> TANK TO P/L WELL BLDG `ANT To ROAD Dt InletTAKE <br /> AIR IN <br /> Septic 7S� 7 d-" NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe <br /> PUMP/SIPHON INFORMATION System �l'7o Yid d <br /> Elevation <br /> Manufacturer Demand Final Grade <br /> Model Number GPM 4.33 00,027 <br /> Lift Fr.Loss Head TDH <br /> Forcemain Length I Dia Dist/Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width (o Length No of Cells Type of System Manufacturer: <br /> SETBACK OHWMofNav M— LEACHING <br /> INFORMATION P{L Bldg wail JWaters CHAMBER Model Number: <br /> CELL TO i SC7 �— <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold 5e_jWn Distribution Pipe /r X Hole Size X Hole Observation Pipes <br /> Length Dia Len Dia �Spac Spacing as ❑No <br /> SOIL COVER <br /> Depth Over. / ® Depth Over dzY Depth of Seeded I Sodded Mulched <br /> Cell Center / Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,a .) <br /> �ah►v�xf4A/ sslcf der 54rr ` b� Components Not Inspected <br /> ^/ <br /> -� Permit Posted Cover Material / er C'X 8 ` <br /> Waring labels on manhole covers w/locks <br /> -p Schedule 40 Vent Material 7, A, O F, <br /> 1d, Effluent Filter installed Model fl0 MF . 17 <br /> Plan revision required?❑Yes;No 1 (R �� oz <br /> Use other side for additional information Date PO Inspector's Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD 66710 R(3101) <br />