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PRIVATE OM$ITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( POWTS) Property Address: <br /> `'►/SC011S1/1 INSPECTION REPORT <br /> Department of Commerce <br /> Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION q(pg1 <br /> Personal information you vide ma be used for sewn ses[Pri Law,s. 15.04(1 m) T,�of: State Plan Transaction ID#: <br /> ill e <br /> Permit H�Ider's Name: � City � I V I �9� <br /> �I�lin I <br /> Ins BM Elev: BM Description: Parcel Tax No: <br /> CST BM Elev: P <br /> 00� s 6�4-aa -tin <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION 8S HI FS ELEV <br /> Septic Benchmark �S Da�SS Od — <br /> Dosing <br /> bon Bldg.Sewer Q. <br /> Holding St 1 Ht Inlet <br /> TANK SETBACK INFORMATION St I Ht Outlet <br /> TANK TO PIL WELL BLDG AIRINTAKE ROAD Dt Inlet <br /> IR <br /> Septic 7S0' W r to / NA Dt Bottom 13-10 . <br /> Installation <br /> Dosing (t I t t NA Contour <br /> Aeration NA Header/Man. r7 3 qS,tl K <br /> Holding Dist Pipe <br /> Infiltrative 8,05 -114,9 <br /> PUMP I SIPHON INFORMATION Surface <br /> Manufacturer Zv elr-- Demand Final Grade <br /> Model Number 16 r-)— GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width r Length r(S :oTs Type of System Manufacturer:LEACHING <br /> oNWM of Nav CHAMBER;INFORJMAATI;ONNSETBACK P1L Bldg waters d W Model Number. <br /> ELL To7�D ' �� N <br /> DISTRIBUTION SYSTEM x Pressure Systems only <br /> Header 1 Manifold Distribution Pipe(s) I X Hole Size X Hole Observation Pipes <br /> Length Dia Length I3 Dia_ Spac—3— <br /> ►50 Spacing ❑Yes D No <br /> SOILCOVER ed Sodded Mulched <br /> Depth Over 11 k Depth Over i Depth of F l <br /> Cell Center t Cell Ed es is To loll 6 Yes O No Yes No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> //J We.(( - 1 . <br /> Permit Posted? (Y N <br /> 5c.�,,e <br /> Schedule 40 Ven``f�said Observation Pipes? N <br /> Cover Material: ft I il"r 6LON <br /> Effluent Filter Manufacturer Model <br /> Components Not Inspected: n r1 < <br /> Plan revision required?O Yes O NoL G <br /> PO S Ins t s Si nature Cert No <br /> Use other side for additional information Date P� 9 <br />