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Via . 6 " Via' <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> VA.Aronsin ( POwTS) Property Address: �`�(r� <br /> Department of Commerce INSPECTION REPORT j k, I?A, <br /> SW*and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide may be used for sewn Pri Law,s.15.04(1 m <br /> Permit Holder's Name: 0 City 0 Village own of: State Plan Transaction Il?ax: <br /> CST BM Elev: Insp BM lev: BM Description: Parcel Tax No: <br /> /00. 00 5AM E IVAIL /Cj W tHl TE PWE /,Z <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 15 KAW 0OO eAj.LaJ Benchmark — .t 47,50 00,C)o <br /> Dosing <br /> Aeration Bldg.Sewer s� 9V 00 <br /> Holding St/Ht Inlet O 93,4Z <br /> TANK SETBACK INFORMATION St/Ht Outlet I 93. <br /> TANK TO I P/L WELL BLDG -ATNNROAD Dt in <br /> Septic 40'+ N/A x IT - NA Dt Bottom <br /> Ding NA Installation <br /> Contour <br /> Aeration NA Header/Man.— <br /> *77 <br /> Holding Dist Pipe .97 <br /> PUMP/SIPHON INFORMATION Infiltrative 9/.90 <br /> Surface 51,- 47 <br /> 51, <br /> Manufacturer Demand Final Grade <br /> Model Number <br /> GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length DiaDist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width(p Length No of Cells Z Type of System Manufacturer. <br /> SETBACK OHWMofNov (COnven�foal LEACHING <br /> INFORMATION P/L Bldg wen Waters CHAMBER <br /> Lh Model Number: <br /> CELL TO _'7V A11A /f//A <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length—&W' Dia Spac Spacing Lbws ❑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.) <br /> Permit Posted? � N <br /> Schedule 40 Vents and Observation Pipes?o N <br /> Cover Material: _i)VPAR. <br /> Effluent Filter Manufacturer A t Model A- /000 <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 9 5��{ �� ZY 7 jo I 3 ' <br /> Use other side for additional information Date POWTSactor's Signatu Cert No <br />