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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Vsconsin ( POWTS) PropertyAddress: <br /> Department of Commerce INSPECTION REPORT %U ,Q1 11 <br /> Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION �5G13 <br /> Personal information you vide ma be used for secondarys PrivacyLaw,s. 15.04 1 m <br /> Permit Holders Name: City village Uf Town of: State Plan Transaction IDN: <br /> Nou p,pz WAGNER OAK/-Au <br /> CST BM Elev: Insp BM Elew BM Description: Parcel Tax No: <br /> /00 - 00 SAM 130T'roM of 510iNG oN 5A5D 020 9/75 05 560 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 1000 6ALLOAJ Benchmark 1,25 /o/.z5 /oo.co <br /> Dosing <br /> Aeration Bldg.Sewer 7¢ 916.51 <br /> Holding St/Ht Inlet s./,9& 4)46. ,q <br /> TANK SETBACK INFORMATION St I Ht Outlet ,:zz 94.0.3 <br /> TANK TO I P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTME <br /> Septic >A0 ;,65 — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. 5737 <br /> Holding Dist Pipe r 95. <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface 6•20 95.0 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width (p Length tog No of Call 1 Type of System Manufacturer: <br /> Co/nt:nnu l LEACHING <br /> INFORMATION <br /> SETBACK P/L Bldg well w ers of Nov CHAMBER Model Number. <br /> Tn-9t�wnc� <br /> CELL To 5f /5 >80' — <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) 4 X Hole Size X Hole Observation Pipes <br /> Length — Dia — Length /05 Dia Spac Spacing 6aYes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depih of Seeded/Sodded Mulched <br /> Cell Center I Cell Edges To soil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? D N <br /> Schedule 40 Vents and Observation Pipes?0 N <br /> Cover Material: T'YeAR <br /> Effluent Filter Manufacturer ;<AA15L� Model A-0oo <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No O I I 71 O 1 3 <br /> Use other side for additional information Date POWTS Ins toes Signature Cert No <br />