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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County� <br /> Visconsin ( POWTS) Property Address:3Wj91 <br /> Department of Commerce INSPECTION REPORT <br /> salary and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal inforastioo you 'de my be used for secondary Pri Law, <br /> Permit Holder's Name: 0 City Ydlage Town of: Slate Plan Transaction ID#, <br /> jakao 15q(,2)- <br /> CST BM Elev: Irsp BM Elev: BM Description: Parcel Tax No: <br /> /00. 00 Sdmc- Gere e SLab -Q -- <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark ,?45 101.4 /00. cc) <br /> Dosing <br /> Aeration Bldg.Sewer 1 q- 99.31 <br /> Holding J5'5 WL.P ;?-C)co 6011w St/Ht Inlet 9773 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG IV TOO ROAD Dt Inlet <br /> IT <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holdingx&S' > 3,r ' Dist Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand I Final Grade <br /> Model Number 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 Length NoofCells Type of System Manufacturer: <br /> SETBACKOHwMaNav kp6men6 LEACHING <br /> INFORMATION P/L Bldg weu waters AIclr„y CHAMBER Model Number <br /> CELL TO 7�/L <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Obs�eervation Pipes <br /> Length Dia Length_ Dia_ Spac Spacing Lei a ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Ed Topsoil ❑Yes ❑No E3 Yes' <br /> ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? /�) N <br /> Schedule 40 Venfs and Observation Pipes?(y) N <br /> Cover Material: A11A <br /> Effluent Filter Manufacturer j11A Model N/A <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No <br /> Use other side for additional information Date PO Inspectors Sign re Cert No <br />