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iQAS60a ,- os mss; u0 <br /> /�/� <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Vsconsin ( POWTS) Property Address: 33115 <br /> Department of Commerce INSPECTION REPORT , ?I, <br /> ,l Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION I <br /> Personal information you provide my be used for secondary ses[Privacy Law,s. 15.04(1 m)I <br /> Permit Holders Name: City Village Town of: State Plan Transaction IDM: <br /> CST BM Ele . Insp BM Elev: BM Description: Parcel Tax No: <br /> /00- 00 SAME '&rrom of 50,06 @CAA O - - <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic WigcoL W4,P /poo A//o. Benchmark / 10171 /00.co <br /> Dosing to OD <br /> Aeration Bldg.Sewer 6 93.33 <br /> Holding St/Ht Inlet 96- 11 <br /> TANK SETBACK INFORMATION St I Ht Outlet 91/ X, <br /> TANK TO PIL WELL BLDG IVENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >,25 3 IQ IP NA Dt Bottom 0198 73 <br /> Installation <br /> Dosing > 15• NA Contour <br /> Aeration NA Header I Man. 3.94 97. 77 <br /> Holding Dist Pipe <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> Surface N.$0 5 <br /> Manufacturer XC)6LL6Q, fDomDemand Final Grade <br /> Model Number >�334 <br /> > GPM <br /> TDH Lift Friction Loss ,231 System Heady TDH 7.3DFt <br /> Forcemain Length Dia:?-1 Dist.To Well > sp <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width 3 Length No of Cells 3 Type of System Manufacturer: <br /> SETBACK OHM �phsX✓1�tav141 LEACHING 131oDIfFUSE2 <br /> P/L Bldg well CHAMBER <br /> INFORMATION waters �h�rcwtd Model Number: <br /> CELLTO > 111 >(ap _ 5TWO^PLO I I <br /> DISTRIBUTION SYSTEM X Pressure Systems only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length-4Z' Dia—t6o� Length Dia_ Spac Spacing I'Yes ❑ No <br /> SOIL COVER <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.) �ow6sT Sys 64caa tion ; 96. 8 2- <br /> Permit <br /> Permit Posted? Y N <br /> Schedule 40 Vents and Observation Pipes? Y N <br /> Cover Material: NW/1 <br /> Effluent Filter Manufacturer %<A i5 Model �-/_ o <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No <br /> Use other side for additional information Date POWTS I or's Signature Cert No <br />