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PRIVATE ONSITE WASTE TREATMENT <br /> Coun <br /> °s p SYSTEMS ty: Burnett <br /> ( POWTS) <br /> INSPECTION REPORTAddress: 6CI99 <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 6-86989 q <br /> Personal information you provide may be used for secondary purposes t Pnvacy Law,s. 15.04(1)(m)t SAN /S pt fy <br /> Permit Holder's Name: ❑City Village Town of: State Plan Transaction ID#: <br /> N a Caa r✓�y gPv�Gw <br /> Insp BM Elew BM Description: Parcel Tax No: <br /> �07/ � S'd � 07-020-1-4o-/1v-23- S <br /> o� � � 'ro� Os"-ODly-0�3o00 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic - 0D Benchmark 31 /44-37 /00. <br /> Dosing <br /> Aeration Bldg.Sewer <br /> .73 <br /> Holding St I Ht Inlet s•D y T, 30 <br /> TANK SETBACK INFORMATION St/Ht Outlet S aii <br /> TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >lo, 7,1S't (of NA DtBottom <br /> Dosing� NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist. Pipe $ j 96.83 <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 3' L #of Cells,2 F Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav Conv ❑ Aggregate Z,t,AL frafo1' <br /> INFORMATION P I L Bldg Well Waters D IGP pt Chamber Model Number: <br /> ❑ AG ❑ EZFIow <br /> CELL TO } 16 L 780' " ❑ Mound ❑ Other K s a <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header!Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length_ Dia Spac Spacing Yes ❑No <br /> SOIL COVER T <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with —f ,e 6&CJAPZz <br /> Filter Manufacturer: 1,' e 7;m-e <br /> Model: G-7 V <br /> Electrician: — <br /> (Field directive given to plumber that all electri,:Mring a necessary be completed by electrician per WI Admin Code.) ❑Yes❑ No <br /> Plan revision required?[] Yes 0 No <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SBD-6710(R.4/14) <br />