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t-VeCt �>-'u-us a - u U <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Visconsin ( POTIIVTS) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Ser*and Wwings Division (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal infommtion ym provide nay be used for secwduwy ses Privacy Law,s. 15.04(I m) a <br /> Permit Holler's Name: U pity village Twin of: State Plan Transaction IDM: <br /> I � <br /> ---Tirn4ji 44 <br /> CST BM Elev: IInsp BM E : BM Description: Parcel Tax No: <br /> J100. 00 s T v of 1/2-" L.. P, 7Y 1 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 1Ah E<'— )00o allow- Benchmark 3.1& ` /03.9(v /00 c0 <br /> Dosing <br /> Aeration Bldg.Sewer 585 /00. t3 <br /> Holding St I Ht Inlet 4.CD' 99. 96 <br /> TANK SETBACK INFORMATION St I Ht Outlet 4.xq, 99 e07 <br /> TANK TO P/L WELL BLDG VENT To ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic mv, AIIA $ ' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe c. 48 r 3 ".401 <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface S'.48 a s • <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> MH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width 3 Length /p& No of Cells 3 Type of System Manufacturer: <br /> SETBACK OHWMofNav cVArXNG/OIKwI LEACHING .1MQLT99hT&P— <br /> INFORMATION P/L Bldg Well waters r.,-owttA'lld CHAMBER Model Number. <br /> CELL TO .V/if — 00ICK <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 W'Yes ❑No <br /> SOIL COVER <br /> Depfh 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 /> Permit Posted? © N <br /> Schedule 40 Vents and Observation Pipes?T N <br /> Cover Material: /V/A <br /> Effluent Filter Manufacturer i31 OTt isr- Model fila $2.2— <br /> Components <br /> 22Components Not Inspected: <br /> Plan revision required?❑Yes❑No I$ 7 O I <br /> Use other side for additional information Date 0011 <br /> spector's Sig re Cert No <br />