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IIIUn ? a LAS <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( POWTS) Property Address:a <br /> Visconsin <br /> eptVof Commerce INSPECTION REPORT <br /> SAft and BuNdings Division (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION g/^ <br /> Personal inibmistion you provide my be used for semom Privacy Law,x 15.04(1 m)I �U <br /> Permit Holders Name: U Cvillage of: State Plan Transaction ID#: <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> /00. oo a u G•AAC1E Ah2e4 0�8 61 S-D-DD-DIM INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic WIE5fx Benchmark 3,10 103.J0'1 /00.00 <br /> Dosing <br /> Aeration Bldg.Sewer .30 96. 70 <br /> Holding St/Ht Inlet b. 2 9 , <br /> TANK SETBACK INFORMATION St/Ht Outlet 5. <br /> TANK TO P/L WELL BLDG 11TO ROAD Dt Inlet <br /> AIR INTAE <br /> Septic B' 3 j' /$ — NA Dt Bottom <br /> Dosing NA installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist Pipe • 7 is 95,Q2 <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface 8. /S 9 .9,Z <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> MH Lift Friction Loss System Head MH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DMENSIONS Width 3 Length 301No of Cel 3 Type of System Manufacturer: <br /> Colluerlva✓10.f LEACHING I NF#L.%RA7DR. <br /> SETBACK P/L Bldg well emote s o1 Nav '„ G�d CHAMBER <br /> INFORMATION \J Model Number. <br /> CELL TO (p' /0 Z12,112, SU.Ce >' 00 OIGK 4 <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_ Spec Spacing &rYes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of. Seeded/Sodded Mulched <br /> Cell Center Cell Ed es To soil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (include code discrepancies,persons present,etc.) fioL': 5ySrE,N IS /' Deqitir r*ry AM). SOILS Atf Surrsc.e ro <br /> Permit Posted?(5 N �t 30 A'vj� '(e/.w ys&. g&'-'e-bon @ BL i 63 <br /> Schedule 40 Vents and Observation Pipes?b N <br /> Cover Material: A//,t <br /> Effluent Filter Manufacturer L Lou<- _ Model <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No <br /> Use other side for additional information Date POWs spector's Signatu Cert No <br />