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PRIVATE ONSITE WASTE TREATMENT <br /> County: Burnett <br /> Y; $ SYSTEMS <br /> :> <br /> Ps;J ( POWTS) <br /> INSPECTION REPORTys <br /> Safety and Buildings Division Address: i01 <br /> (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION sga75o <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)I <br /> Permit Holder's Name: ❑City ❑ Village IH Town of: State Plan Transaction ID#: <br /> y"eiI X7 11 CCe r <br /> Insp BM EleVP BM Description: Parcel Tax o: <br /> .L 51o5- Oo�1.0/a Doo <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septicys- Benchmark 3 A 9b, /aO.nO <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St I Ht Iplet 191.4wy. <br /> TANK-SETBACK INFORMATION StlHit Outlet <br /> TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic 71� >aS 74 NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header:Man. s ' <br /> Holding DisCPipe S,, 90•7y <br /> PUMP/SIPHON INFORMATION Surface <br /> Infiltrative <br /> Suace <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 r Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav <br /> ❑ Conv ❑ Aggregate L1•�e�::n r <br /> INFORMATION P/L Bldg Well Waters IG ❑ Chamber Model Number: <br /> ❑ AG <br /> ❑ EZFlow <br /> CELL TO ❑ Mound ❑ Other 81,dh,,c Ff D$ <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipe(s) X Hole Size --FX-Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing ❑Yes ❑ No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes 11No ❑Yes 11No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Elevations taken with <br /> Filter Manufacturer: L..),r/,- t' <br /> Model: *4 og <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?❑ Yes[�No J-010 9.0 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SRn-AM iR 41141 <br />