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"""T PRIVATE ONSITE WASTE TREATMENT <br /> -� Burnett <br /> SYSTEMS county: <br /> s INSPECTION REPORT Address: -7 ; <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No; -s—y L1-s 3 <br /> GENERAL INFORMATION S/� ;v — I j _9- <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(t)(m)] <br /> Permit Holder's Name: ❑City ❑ Village own of: State Plan Transaction ID#: <br /> Insp BM Elev: BM Description: Parcel,a._c - .�." �_ <br /> b t 0 ��44 O� ��G� Sf4O-1�(� '�� � ®Q�-� II140 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark �,p0 I io) oo 1 0 0 <br /> Dosing <br /> Aeration Bldg, Sewer `3.0 y <br /> 'Holding J�D St/Ht Inlet , I 96 , 9 <br /> TANK SETBACK INFORMATION St I Ht Outlet 3 91--5 7 <br /> TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic NA Dt Bottom <br /> Dosing' NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holdin 70 10 n/ N Dist.Pipe <br /> IW Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade f1/ <br /> Model Number GPM "I c7 W s,q <br /> TDH Lift Friction Loss Sys Head TDH Ft ��- <br /> Forcemain L I Dia F Dist,To Well Top of lid <br /> DISPFERSAL-CELUNFORMATIGN- <br /> DIMENSIONS W L #of Cells "iypeaSystem Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ° Conv ❑ �eg.;�te <br /> P/L Bldg Well ❑ IGP ❑ Chamber <br /> INFORMATION Waters ❑ AG J:a EZFiow MmeLCELL TO ❑ Mound ~� <br /> DISTR X Pressure Systems Only <br /> Header/Manifold Distribution Pipes) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing ❑Yes ❑No <br /> -Soft-eovm <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Ceil Edges Topsoil []Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Elevations taken with 1Ae k.rt' lvn <br /> Filter Manufacturer: <br /> Model: --- <br /> Electrician: t'I <br /> (Field directive given to plumber that all electric/wiring when necessary to be ompleted by electrician per WI Admin Code.) ❑ es No <br /> Plan revision required?❑Yes No 7 ) I &✓ �� 3 S 3 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />