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. i✓1 �,1� a t.,�U =..c�,/� �°�. /z �� — l�s�N�u-�_ <br /> Visconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS BurnettCounty <br /> (Powys) Property Address 'a-7a3- <br /> Department of commerce INSPECTION REPORT �,��l �5LK <br /> Sa"and&"lung°Division (ATTACH TO PERMIT) . <br /> PA <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Pasonal infornation ou providem be used for secondary �MLtnq Law,s.15.04(1)(m) <br /> Permit <br /> tHHo]ld�e7�r-sName: n City Ll village Town of: State Plan Transaction IDk: <br /> CST BM Elev: Inap BM Eltfv: BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA ORO-6)100-03- <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic KAW /CrXj Benchmark <br /> Dosing Gw+r4wAEWe <br /> Aeration <br /> Bldg. <br /> HoMulg St/Ht iniet <br /> Inlol <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANK TO I PIL WELL BLDG AIR INNT race ROAD Dt Inlet <br /> �Ptic �2o i�` ' / r — NA Dt Bottom <br /> Dosing a NA Instanation <br /> Z (S' Contour <br /> A irehon NA Header/Man. <br /> Holding Dist Pipe <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number <br /> GPM <br /> TDH Lift Portion Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DWENSKINS Width Length No of cels Type of System Manufacturer. <br /> SETBACK OHWrdofNaw -1I LEACHING <br /> INFORMATION P/L Bldg Wag waters &AA<4we r CHAMBER Model Number. <br /> CELL TO Ory <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) 1X Hole Size X Hole Observation Pipes <br /> Length_ Dia_ Length_ Dia_ Slow I g <br /> No <br /> SOIL COVER Pn9 ❑Yes ❑ <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Ed-qes To soil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> r4Nrc R6Pt.acs�fr� FoA- N6w, Z 86oRawt il./eu.rw. <br /> Permit Posted? (ON /000/(000 Co.MlxI Tarr- uslact 76 Acco w.o rro- iI <br /> Schedule 40 Vents and Observation Pipes? It N tzslwe"wr oe x>"w rsco. <br /> Cover Material: dIA <br /> Effluent Filter Manufacturer jr csr Model 6F /O- S <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 2( �a O-T 7 O <br /> f 3 <br /> Use other side for additional information Data PO Inspector s Si "lure Cert No <br />