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' PRIVATE ONSITE WASTE TREATMENT SYSTEMS county (fY etc <br /> Wisconsin '' ( POWTS) <br /> Department at commerce INSPECTION REPORT <br /> Safety and aeildr,s Drvrsioe (ATTACH TO PERMIT) Sanitary Permit No <br /> GENERAL INFORMATION <br /> int imam goo fee,&:may nv nncd for= onda w s=I P.a.ao raw.s. 15.041 o ado I <br /> Permit Holder's Name: City m Village Town oC Stale Plan Transaction IDC <br /> E V : <br /> aO <br /> CST BM lav: Insp BM Elev: BM Description: Parcel Tax No: (�/�"Q� <br /> a- +D-iC2 �a� <br /> /G�.co S� -roe o/ �cK — <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic .J_,.)FILYoTOR. 10.50'6alLwr Benchmark 0.4Z /00.q.2- IG12.00 <br /> Dosing <br /> Aeration Bldg,Sewer <br /> Holding St I Ht Inlet 2,95 97.67 <br /> TANK SETBACK INFORMATION St I Ht Outlet ,?96, 97 '{!o <br /> TANK TO P/L I WELL I BLDG I vFIRaNr i0iPKE ROAD DI Inlet <br /> IN <br /> Septic 30v z35• �"lg' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header Man. <br /> Holding Dist.Pipe <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head — TDH Ft <br /> Forcemain Length Dia I Dist.To Well <br /> DISPERSAL CELL INFORMATION -,5ta AwnF+tld. <br /> DIMENSIONS Width /Z• Length 3,;. Ni 1 Type of System Manufacturer: <br /> SETBACK OMwM of Nov -5&,e6L 7, LEACHING <br /> INFORMATION PIL Bldg .. We! . waters of /le//atu....t CHAMBER <br /> Model Number <br /> OUL <br /> CELL TO 'c,b' +•25' >So x (cO <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Dis n "on Pipets) X Hole Size t: X Hole Observation Pipes <br /> Length Dia Length_ Dia Spac Spacing ❑Yes [:] No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> BCAP- jWjrjW ,c rlZer fn be m56:,1(rF( <br /> /vrG lir K .LYL+rwf Ohl}y. <br /> Plan revision required?0 Yes O No I L-1 o 3 <br /> Use other side for additional information Date PO S Inspector's Si ure Cert No <br />