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�hLtrs- Ib-5� 10 .3o F <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS I Burnett County <br /> �I*Isconsin ( POWTS) _��Ad�: <br /> (/ Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) 7� �� - _.I <br /> Sanitary Permit No: <br /> GENERAL INFORMATION y�ca <br /> Personal information you ma vide be used for secondaryses PrivacyLaw,s. 15.04(i m <br /> Permit Holders Name: Li city Village Town of: State Plan Transaction ID6: <br /> b0rtn L-0VA/ Sepf � <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> NAIL ,N &o, 0kiL 15" 0 a�r lily oa ado <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS I ELEV <br /> Septic w S5E12 750 AIJb11 Benchmark S SD dap Vp <br /> Dosing <br /> Aeration Bldg.Sewer <br /> 97. 3o <br /> Holding St I Ht Inlet 15 415 7. 05 <br /> TANK SETBACK INFORMATION St/Ht Outlet 4 iw <br /> TANK TO P/L WELL BLDG �"T TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic > o 'V/A IC5, — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> Surface `J. ,?D 943o <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 Length No of cells Type of System M nufacturer. <br /> SETBACKp/L Bldg waa DHWM a Na' CaRxn6ronal LEACHING 8 I FFD Ste <br /> INFORMATION g waters r„9ra„� CHAMBER M el Number <br /> CELLTO /Go- ,Z0'+ MIA in f/I� G <br /> DISTRIBUTION SYSTEM X Pressure Systems Onl <br /> Header I Manifold Distribution Pipe(s) X Hole Size X Hol Obs�eervation Pipes <br /> Length_ Dia Length_ Dia_ Spec Sped n lid Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Ed es Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? Q N <br /> Schedule 40 Vents and Observation Pipes?& N <br /> Cover Material: A11A <br /> Effluent Filter Manufacturer Abd(- Model A -ko- iZ <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No OJl blo 7 6 I ( 3 <br /> Use other side for additional information Date POWiS I ors Signature Cert No <br />