Laserfiche WebLink
/ V�e.WT.Nr 4r <br />Safety and Buildings Division <br />PRIVATE ONSITE WASTE TREATMENT <br />SYSTEMS <br />(POWTS) <br />INSPECTION REPORT <br />(ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />Personal information you provide may be used for secondary pu oses [ Privacy law, s. 15.04 (1Xm) <br />Permit Holder's Name: <br />❑ City Ll Village Town of: <br />e%AN;e Ae41 <br />Septic <br />Insp BM Elev: <br />BM Description: <br />/Do <br />WA 5,e a Z`ec. fo 41e <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />AIRI NTATA KE <br />AIR I <br />ROAD <br />Dosing <br />.7 JD' <br />7 a 5 <br />Aeration <br />L <br />NA <br />Holding <br />Waters <br />CELL TO <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />AIRI NTATA KE <br />AIR I <br />ROAD <br />Septic <br />.7 JD' <br />7 a 5 <br />$' <br />L <br />NA <br />Dosing <br />Waters <br />CELL TO <br />Bldg. Sewer <br />NA <br />Aeration <br />St / Ht Inlet <br />NA <br />Holding <br />St / Ht Outlet <br />3 S, <br />PUMP I SIPHON INFORMATION <br />Manufacturer <br />W <br />Demand <br />GPM <br />Model Number <br />SETBACK <br />TDH Lift <br />Friction Loss <br />Sys Head <br />TDH Ft <br />Forcemain <br />L <br />I Dia <br />I Dist. To Well <br />DISPERSAL CELL INFORMATION <br />DIMENSIONS <br />W <br />L <br /># of Cells <br />SETBACK <br />P / L <br />Bldg <br />Well <br />OHWM of Nav <br />INFORMATION <br />a EZFIow <br />❑ Mound <br />Waters <br />CELL TO <br />Bldg. Sewer <br />DISTRIBUTION SYSTEM <br />County: Burnett /]#0f <br />Ye <br />Ve <br />Address: YeLCow L"t, /SG( <br />Sanitary Permit No: Cv�G7,70 7 <br />S11/t/- /9-o 9 <br />State Plan Transaction ID#: <br />Parcel Tax No: <br />D7-036 <br />S I -r- 060 - 0/7,060 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />— a , to <br />% y p <br />Model Number: <br />pd,� <br />a EZFIow <br />❑ Mound <br />❑ Other <br />Bldg. Sewer <br />St / Ht Inlet <br />9, as <br />St / Ht Outlet <br />3 S, <br />Dt Inlet <br />Dt Bottom <br />Installation <br />Contour <br />Header / Man. <br />Dist. Pipe <br />Infiltrative <br />Surface <br />Final Grade <br />Top of lid <br />Type of System <br />Distribution Media <br />Manufacturer: <br />❑ Conv <br />❑ Aggregate <br />❑ IGP <br />a Chamber <br />Model Number: <br />❑ AG <br />a EZFIow <br />❑ Mound <br />❑ Other <br />X Pressure Systems Only <br />Header/ Manifold <br />Distribution Pipe(s) <br />X Hole Size <br />X Hole <br />Observation Pipes <br />Length Dia <br />Length Dia Spac <br />Spacing <br />1 ❑ 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 <br />90 <br />Filter Manufacturer: l: Ae <br />Model <br />Electrician: <br />(Field directive given to plumber that all electriGwirin wh nec sa o be completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />Plan revision required?❑ Yes No j <br />Use other side for additional in ormation Date / POWTS Inspector's Signature Certification Number <br />SBD -6710 (R.4/14) <br />