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q <br /> Visconsin <br /> PRIVAT O SITE WASTE TREATMENT SYSTEMS Bumett County <br /> ( POWTS) Property Address: <br /> department of Commerce INSPECTION REPORT <br /> Stty and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION j� <br /> Personal informatlon you a provide n be used for secondaryPriv Law,s.15.04(1)(m) `-1 <br /> qgqS— <br /> Permit oiler's Name: State Plan Transaction ID#: <br /> r C� Town of: <br /> CST BM Elev: l IInnsp BM Eley: BM Description: I Parcel Tax No: <br /> S I 101LqUIS-61 -a/lD <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic —Nonjesch Benchmark SS <br /> Dosing <br /> Aeration Bldg.Sewer ,Z <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG aRM o ROAD Dt Inlet <br /> Septic , ME <br /> NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist.Pipe (1 R ` <br /> PUMP 1 SIPHON INFORMATION Elevation (o a 13og <br /> Demand Final Grade Q� <br /> Manufacturer <br /> Model Number GPM ueeq jq. <br /> TDH Lift Friction Loss System -lead TDH Ft —T O <br /> Forcemain Len I Dia I Dist Well 3.35 6- <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width (, LengthNo of ceus a Type of System Manufacturer. <br /> LEACHING <br /> SETBACK P/L Bldg well ��of Nav zh'9 rdcch CHAMBER -- <br /> INFORMATION waters cc�l Model Number: <br /> CELL TO <br /> DISTRIBUTION SY TEM X Pressure Systems Only <br /> Header/Man ifol p Distributi ipe(s) r X Hole Size X Hole Observation Pipes <br /> Length Length ' Dia Spac Spacing es ❑No <br /> SOIL COVW <br /> Mulched <br /> Depth Over <br /> Cell Center l LI0/ Depth <br /> eE Over DepM of T 13 Yes 0 No <br /> Seeded/Sodded E3 Yes 13 No <br /> COMNT$: (Incre i an / n(p It,etc) <br /> �� <br /> Components Not Ins clad <br /> NA Permit Posted Cover C <br /> Material F� l �r 4Ap. el( sf/fi d <br /> v' Warning labels on manhole covers w/locks <br /> 16 Schedule 40 Vent Material <br /> I' Effluent Filter inst lied Model MFR. <br /> Plan revision required?❑Yes 60 q Z a y Q S 9 <br /> Use other side for additional information Date PbWS Inspector's Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison 1M 53701-7302 SBD-8710 R(8/01) <br />