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Visconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett Countyry// /I( Powis) Property Address:a 10"T <br /> Department of commerce INSPECTION REPORT <br /> Sam ON BuiWirW Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> 1'a3onl inforamtioa you provide my be used for seconduwy f Privacy Law,s. 15.04(1 ao <br /> Pamlt Holders Name: City village Town d: State Plan Transaction IDA: <br /> CST BM E Imp BM Elev: BM Description: Parcel Tax No: <br /> b3y-g0aG-ol— <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Sasro* I'll/t~4Ea2 Benchmark <br /> Dosln9 !e <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 1 lJII (G i <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG VENT <br /> TOE ROAD Dt InletAIR <br /> Septic : 7p *49 s.5' NA Dt Bottom <br /> Installation <br /> Dosing *75 *so, x-IS, > Z0, NA Contour <br /> Aeration NA Header I Man. <br /> Holding Dist Pipe <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Dwnand Final Grade <br /> Model Number GPM <br /> MH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I DisL To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width Length Noor Cak Type of System Manufacturer. <br /> OHWM �� a / LEACHING <br /> INFORMATION ION CK P/L Bldg well w dNav y t_ 0'V'4 CHAMBER t-Atg Model Number <br /> CELLTO H1H <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 /> Ceti Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? (y) N <br /> Schedule 40 Vents and Observation Pipes? 6L N <br /> Cover Material: HIAA <br /> Effluent Filter Manufacturer DoLY.4C16-K Model 525 <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No j D 7 D I 3 / <br /> Use other side for additional information Date PO S I or's Signatl Cert No <br />