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Visconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( POWTS) Property Address: <br /> Department of commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> 0 <br /> Sanitary Permit No: <br /> GENERAL INFORMATION /1,rom��3 <br /> Personal information you provide m be used for second u Priv Law,s. 15.04(1 Xm) `t <br /> _I <br /> Permit Holders Name: n 33— <br /> State Plan Transaction IDB: <br /> Town of: <br /> CST BM Elev: Insp BM Elev: jBiM Description: Parcel Tax No: <br /> /00.00 SAM15 )JAIL AA) 4Vt4)TE Aic '7 — <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic d IR was Ga IL� Benchmark .25 /00. �IS /00.00 <br /> Dosing <br /> Aeration Bldg.Sewer 2,3 3 97. ?z <br /> Holding St/Ht Inlet 4. 33 95 9Z <br /> TANK SETBACK INFORMATION St I Ht Outlet 45s C6. 107 <br /> TANK TO AIR IN(AP/L WELL BLDG VENT TA KE ROAD Dt Inlet <br /> Septic >50 ,d/A ,Z5'�^ NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header l Man. ISO i.5439 25- <br /> Holding Dist.Pipe <br /> PUMP I SIPHON INFORMATION System <br /> Elevation S,3 y6,4* 9 X93.59 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> Lift Fr.Loss Head TDH <br /> Forcemain Length I Dia Dist/Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width (o Length 75 No of Calls Z Type of System Manufacturer: <br /> SETBACKp/L Bldg Well OHWM of Nav LEACHING <br /> INFORMATION g Waters CHAMBER Model Number: <br /> CELL TO x.70 135' */'i "V/,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--7> Dia`�" Spec I Spacing 11Y s ❑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.) <br /> Components Not Inspected <br /> >2r/ Permit Posted Cover Material 7YPAQ <br /> "aming labels on manhole covers w/locks <br /> di,/Schedule 40 Vent Material <br /> 117/ Effluent Filter installed Model A - 1 60 61SL_, <br /> Plan revision required?❑Yes❑Noi7 N� 7 0 I 3 7 <br /> Use other side for additional information Date POWT Inspector's Sig lure Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R 3/011 <br />