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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burrett County <br /> Visconsin ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT /w 94MM5 <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION Sz/OBB <br /> Pcsonal information you prowde may be used for recondary I Privaq Lew,s. 15.04(1 m <br /> Permit Holders Name: City Ydlage UPown of: State Plan Transaction IDK: <br /> NWAWGSt ASsa A T/ -rr -t- <br /> CST SM Elev: I Insp BM Elev: BM Description: Parcel Tax No: <br /> /00 9/,14 ",enot ©A Tnk /n/C� " 028 4111 v 3 coo <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic GaUoH Benchmark 7. ?4 <br /> Dosing <br /> Aeration Bldg.Sewer 4.em 3.02 <br /> Holding St I Ht Inlet 6.17 91. 77 <br /> TANK SETBACK INFORMATION St/Ht Outlet '539 9 <br /> TANK TO PIL WELL BLDG I VENT To <br /> rw ROAD EBottom <br /> 30 91.14 <br /> Septic >iCo >So 9, NA Dosing NA Aeration NA an. <br /> Holding <br /> Infiltrative <br /> PUMP 1 SIPHON INFORMATION Surface <br /> Surface <br /> Manufacturer I Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Foroemain Length Dia I DisL.ToWeil <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width Length No of Calls Type of System Manufacturer: <br /> SETBACKaiwMorNa Iwanou ac- a, LEACHING <br /> INFORMATION P/L Bldg well waters -eeEiG T.„r a CHAMBER Model Number. <br /> As) Nrlsn✓G <br /> CELL TO AowrS <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.) AICTC: Se/b (- r—o 5cwe, a be.-El,evom- <br /> Permit Posted? t N f&Adcd. l„ 8 btnl�Gw9. �l/o &W,6l,.t>( cKX1#uxW( W <br /> Schedule 40 Ven s and Observation Pipes?C7Y N '"L°11Le in pow 6y occurs. <br /> Cover Material: */A <br /> Effluent Filter Manufacturer. gEsr Model GF /0-S <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 1� -710 <br /> r 3Ll I <br /> Use other side for additional information /`Date POWTS I pectors Signatu Cert No <br />