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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Bumett County er <br /> Visconsin ( POWTS) Property Address &a /Q <br /> c <br /> Department of Commerce INSPECTION REPORT <br /> safety erne Buildings Division (ATTACH TO PERMIT) Sanitary Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you Provide my be used for secondary Privacy Law,s. 15.04(1)(m) .J <br /> Permit Holder's No e: City I village Tam of: State Plan Transaction IDN: <br /> it oirt <br /> CBT BM Elev: Imp BM Elev: BM Description: Parcel Tax No: <br /> /00.o0 sere W14 fH Ud6 AAPJ,, Tref; a a- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 1950 Il Benchmark 1.Ar 10127 <br /> Dosing <br /> Aeration Bldg.Sewer 12.40 <br /> 97 <br /> Holding St/Ht Inlet 13- 47) 9 <br /> TANK SETBACK INFORMATION St/Ht Outlet / <br /> TANK TO P/L WELL BLDG �INTAKE ROAD Dt Inlet <br /> Septic >/,V >180 > NA Ot Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe qlf r �• 9 . 20 <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface C.Itz, 5.90 109.77 14,4o 1 95 3T <br /> Manufacturer Demand Final Grade <br /> Model Number GPM pteC ll ce f z to 3p 194,97 <br /> TDH Lift Friction Loss System Head TDH Ft lepl Dolt L ? 9 / <br /> FORD main Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width es I Length /db No of Cees z Type of System Manufacturer: <br /> �yver� LEACHING <br /> INFORMATION P/L Bldg - wee w Of ;n�� t CHAMBER Model Number. <br /> CELL TO >/o • > <0O >Is0 X235, <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length= Dia Length_2!E Dia `f" Spec Spacing M Yes ❑No <br /> SOIL COVER <br /> Doth Over Depth Over Depth of Seeded/Sodded Mulched <br /> CeN Center Cell Edges_ To it ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) 5cw4 A"cii. x) Gens n66 coaQlr6e In Spec /00 <br /> Permit Posted? Y N <br /> Schedule 40 Vents and Observation Pipes? Y N <br /> Cover Material: "T'VPAk <br /> Effluent Filter Manufacturer BEs-• Model (F/0 -8 <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No Og 7 0 1 I 3 1 <br /> Use other side for additional information Date POTS ignatuna CertNo <br />