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IVY""T"`� PRIVATE ONSITE WASTE TREATMENT <br /> $ ... \ County: Burnett <br /> SYSTEMS <br /> ( POWTS) gwgw <br /> INSPECTION REPORT Address:ZAI yel4ty i ieY N. <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit No: -9ySyS' <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)] SAti—/7—99 <br /> Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: <br /> -SAlei ltle e/lv La.v <br /> Insp BM Elev: BM Description: n Parcel Tax No: <br /> 07-Da6-a-410-/6-07-s <br /> /s— 6100 — 019000 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic ,'e S e 7 S-p Benchmark <br /> Dosing <br /> Aeration Bldg,Sewer <br /> Holding St/kR Inlet <br /> TANK SETBACK INFORMATION St/fit Outlet <br /> TANK TO P/L WELL BLDG VENT T AIR INTAA KE ROAD Dt Inlet <br /> Septic ;,;-s' 7a5-' �$' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe &f SSA. S,7a <br /> PUMP/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 Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ❑ Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters Q IG ❑ Chamber Model Number: <br /> ❑ EZFlow <br /> CELL TO ❑ Mound ❑ Other <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 <br /> Depth Over I Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center I Ceil Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Elevations taken with a 14 ii <br /> Filter Manufacturer: oL Cok <br /> /� �lf�`ace.+�c�v7� �,vL�• Model: <br /> Electrician: <br /> (Field directive given to plumber that all electri Wring wh n necessary to be completed by electrician per WI Admin Code.) ❑Yes❑No <br /> Plan revision required?❑Yes 0 No -/ /3 /7V,/ v( a 6033 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />