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Asconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( POWTS) Property Address: <br /> " Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide may be used for secondary pu f Privacy Law,s.15.04 I m) <br /> Permit Holder's Name: State Plan Transaction ID#: <br /> Town of: � Cc <br /> CST M Elew Insp BM Elev: BM Description:W hJ Parcel Tax No: <br /> A06r Ai90.CXD 13oTT0jL4 Of- 61D)NG 8-3 - 5-01- o�Cu <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 5K 10 e0Q CSAL Benchmark 470 /0/. 7 ino.00 <br /> Dosing <br /> Aeration Bldg.Sewer 5,70 9 <br /> Holding St/Ht Inlet -5073 <br /> TANK SETBACK INFORMATION St/Ht Outlet �,qa <br /> TANK TO I P/L WELL BLDG 11TOAIR INTAKE ROAD Dt Inlet <br /> Septic >(,p /(p — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe <br /> PUMP I SIPHON INFORMATION System <br /> Elevation 7 Q y <br /> Manufacturer Demand Final Grade ,Z r <br /> Model Number GPM <br /> Lift Fr.Loss Head TDH <br /> Forcemain Length Dia Dist/Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width Length 7tl No of cells Y Type of System Manufacturer: <br /> SETBACK OHwMofNay xrain.t( LEACHING <br /> INFORMATION P/L Bldg well waters Zn-�ra rc CHAMBER Model Number: <br /> CELL TO '35 ) 601 <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length ?D DiaOft Spac — Spacing ❑Yes ❑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.) DAAw F&Lj) AAi6i.6S 799ol6t( T6ST6D Ak6A <br /> 5r,ll_S AP-6 SAoo, wlrrt No L-imirPwf- Ftcroa. rA)oiGATco. L>40rN of Components Not Inspected <br /> SYSTEM, &6eo OtJ G9v.** grL60AP00J, IS Sha.//"er Tls,,., P/016 jivpbsej. <br /> si� Permit Posted Cover Material -TVPAQ <br /> t;' Warning labels on manhole covers wAocks <br /> w' Schedule 40 Vent Material <br /> lu�' Effluent Filter installed Model A 1800 . �A <br /> Plan revision required?❑Yes❑No 7 Q I 3 I <br /> Use other side for additional information Date POWT ors Signa Celt No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBO4710 R( 1) <br />