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T"`�r PRIVATE ONSITE WASTE TREATMENT <br /> 14F% . <br /> SYSTEMS county: Burnett <br /> ( POWYS) CCS►^ Slay <br /> INSPECTION REPORTAddress: A7G/8 <br /> Safety and Buildings Division _ <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit No:s$D7-VI <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(t Xm)] <br /> Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: <br /> 11 <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> 07-0/9-A-W -/s-d8-s <br /> /S-/oo-03300 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septics 9,0 p Benchmark $Ij qq r4D pQ,00 <br /> Dosing <br /> Aeration Bldg.Sewer 3-�(a t0 <br /> Holding St/Ht Inlet 916 94M <br /> TANK SETBACK INFORMATION St/Ht outlet S,I$ <br /> TANK TO P/L WELL BLDG vENTTo ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic 7 >a 5' ti/,4 NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe S, 4 to 93,9y <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> Surface to'Lo 9 a•,�o <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss Sys Head TDH Ft <br /> Forcemain L Dia I Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W 3, L ,7(0'+ yy'_/ap' #of Cells/.k Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav (K Conv ❑ Aggregate 1,v p�fer <br /> INFORMATION P/L Bldg Well Waters ° GP b Chamber Model Number: <br /> ❑ <br /> ❑ EZFIow <br /> CELL TO 7 aS' S�/' — ❑ Mound ❑ Other do.rt-.IC 4-/-L. Lrs <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length 1 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.) Elevations taken with go-557o ✓ <br /> /1,f/ T mg,--e = Glow For Filter Manufacturer: f;Ae 41',wr <br /> e2 eguaL GcGL Le..1jif Model: Lf v8 <br /> Electrician: <br /> (Field directive given to plumber that all electrictwiring when necessary to be completed by electrician per WI Admin Code.) ❑Yes❑No <br /> Plan revision required?❑Yes If No Ig W <br /> F aa o g 33 <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br /> SBD-6710(R.4/14) <br />