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/O — Aep--O / /, Cid h1 <br /> `� s'n PRIVATE ONSITEWASTE TREATMENT SYSTEMS county <br /> POWTS <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 ses I Privacy Law,s.15.04(1)(m)1 a69 <br /> Permit Holder's Name: State Plan Transaction ID#: <br /> ;.,o rL 11052�1c3I ❑City YN Town of: <br /> CST BM Elew Insp BM E BM cription: Parcel Tax No: <br /> 17: <br /> I � -� - b <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI ---FS---I— ELEV <br /> Septic MINS <br /> 3ec Benchmark .0 <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht outlet r) ba, <br /> TANK TO P/L WELL BLDG In R�uri°nla ROAD Dt Inlet <br /> Septic >100' 1001 —>!5/ 1(J14- NA Dt Bottom <br /> Dosing NA Installation <br /> Contour Cel <br /> Aeration NA Header/Man. <br /> Holding <br /> Dist Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative r <br /> Surface 05 !(:.50, go.5a <br /> Manufacturer Demand Final Grade q <br /> Model Number GPM hole �{•s <br /> TDH Lift Friction Loss System Head TDH R <br /> Forcemain Length Dia Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Widths' Lengthr No of cells o2— Type of System Manufacturer. <br /> SETBACK ProPoSe &Aif'G OHWMofNav I SS LEACHING &p_ DI <br /> INFORMATION P/L Bldg wail Waters Ca11Q.I bP CHAMBER Model Number. <br /> CELL TO >1001j' >IW' >JOp' ola TuG-.�d <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold rr Distribution Pipe(s) X Hole Size X Hole rvation Pipes <br /> Length�� Dia Length_ Dia_ Spec Spacing Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center a,ia. <br /> i ba-[Depth <br /> Topsoil 11 Yes 13 Non voe n ti <br /> COMMENTS: (Incidde code discrepancies,persons present,etc.) y •� <br /> Com onents Not Inspected <br /> �( D 1dt'�or new wel( <br /> Permit Posted Cover Material <br /> Warning labels on manhole covers w/locks <br /> Schedule 40 Vent Material <br /> Effluent Filter installed Model -/ MFR. __ <br /> Plan revision required?❑Yes D No 10 <br /> Use other side for additional iininformation Date POWTS Inspector's Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 38D-8710 R 13101 <br />