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Visconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( POWrs) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION g <br /> Personal information you provide may be used for second ses Privacy Law,s. 15.04 txm <br /> Peolder s Name: //11 State Plan Transaction ID#: <br /> L��ew)s Town of: l <br /> CST BM Elew Insp BM Elev: BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic S KA w 8aU sac. Benchmark $ /02. 0 /00.00 <br /> Dosing <br /> Aeration Bldg.Sewer 7 9565 <br /> Holding St 1 Ht Inlet 7, 07 95.(01 <br /> TANK SETBACK INFORMATION St I Ht outlet VS 95- 43 <br /> TANK TO I P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic ' N,q S' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe 7 5Z. <br /> PUMP/SIPHON INFORMATION System <br /> Elevation �b <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> Lift Fr.Loss Head TDH <br /> Forcemain Length ' Dia Dist/Well <br /> DISPERSAL CELL INFORMATION - <br /> DIMENSIONS Width 3 Length 9d NootCells 1 Type of System Manufacturer: <br /> SETBACKOHWMofNav LEACHING E Floc) <br /> INFORMATION P/L Bldg well Wars /1 CHAMBER Model Number: <br /> CELL TO ,SS' / — > Cas' (i S/A KQ&ZQ <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipe$ <br /> Length Dia Length_ Dia Spac Spacing 11Yes ❑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.) <br /> Components Not Inspected <br /> ar Permit Posted Cover Material 7�VAR, <br /> IY Warning labels on manhole covers w/locks <br /> rr Schedule 40 Vent Material <br /> ar-Effluent Filter installed Model A -/SW MFR. ZA16 <br /> Plan revision required?❑Yes❑No 13 1 <br /> Use other side for additional information Date POWTS or's Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R(3101) <br />