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Wed /-/(g Y oo 9TH"fV- vva`f* <br /> PRIVATE ONSITE WASTE TREATMENT <br /> SYSTEMS County: Burnett <br /> POWTS) <br /> ' INSPECTION REPORT <br /> Address: Z 30/9 L7y (t i1I <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION S-&4 9�y <br /> Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] /- 7F <br /> Permit Holder's Name: ❑City Ll Village IF Town of: State Plan Transaction ID#: <br /> Atin2�� 1;11geSNlAGL wt�n� (zlV61Z <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> N <br /> Ad0• Do A1,441, /N Z OAlG d�001 - ol2da0 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic SI-Rw /000 Benchmark (, y3 lot-443 <br /> Dosing <br /> Aeration Bldg.Sewers 0 93,$ <br /> Holding St/Ht Inlet -7.(o5' f3.71 <br /> TANK SETBACK INFORMATION St/Ht Outlet -7•7-2 y •(oL <br /> TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet ?. 17 qe� <br /> AIRINTAKE ' S.GG <br /> Septic *>-T, Asa' 5-2' NA Dt Bottom <br /> Dosing N • NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number S`y GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Foroemain L I Dia Z" I Dist.To Well Top of In Wilke0 ows.r <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells FType of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ° Conv ye Aggregate <br /> INFORMATION P/L Bldg Well Waters ° GP ❑ Chamber Model Number: <br /> 0 <br /> o EZFIow <br /> CELL TO Mound o Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing ❑Yes ❑ No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with 4n nW-AAvR97- <br /> A;evta,•*5 t7t,,a T- Fan- ^66u /Nw, dA16A,1 7�Y/yc A ilter Manufacturer: >3 <br /> ,Zt ,��w QncwUwb 5c � N&w ErI1 �d��. Model: mL.3-9« <br /> Electrician: Pt�"X ejt- ex <br /> (Field directive given to plumber that all electric/wiring when necessary to be completed by electrician per WI Admin Code.) VYes❑ No <br /> Plan revision required?❑Yes J6 No �(� y /_ /,ZG/psp <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SBD-6710(R.4/14) <br />