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y �pSP <br />s , <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 purposes [ Privacy Law, s. 15.04 (1 xm) <br />Permit Holder's Name: <br />❑ City ❑ Village 171 Town of: <br />/ � i%afZ�i° <br />PC <br />scop <br />Insp BM Elev: <br />BM Description: <br />neo, Pb <br />0� <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />T IAleSG o <br />1DoD <br />Dosing <br />> D` <br />7aS <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 />AIR I TONTAKE <br />AIR <br />ROAD <br />Septic <br />> D` <br />7aS <br />/$' <br />L <br />NA <br />Dosing <br />Waters <br />CELL TO <br />Bldg. Sewer <br />NA <br />Aeration <br />St / Hf Inlet <br />NA <br />Holding <br />St / bft Outlet <br />a <br />167-3 <br />PUMP / 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 />Dia <br />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 Nay <br />INFORMATION <br />❑ Mound <br />o Other <br />Waters <br />CELL TO <br />Bldg. Sewer <br />DISTRIBUTION SYSTEM <br />County: Burnet i�'x�0 <br />Address: /T/GL /7a <br />Sanitary Permit No: 6�9c� 75 3 <br />SAiV -18- ss <br />State Plan Transaction ID#: <br />A44 <br />Parcel Tax No: <br />�7-oa8-a- -.3� - s <br />DS oo�- p/Soso <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />', .3-�'- <br />/o;7 <br />❑ AG <br />/00.00 <br />❑ Mound <br />o Other <br />Bldg. Sewer <br />St / Hf Inlet <br />, (p (9 <br />/Dy ?j <br />St / bft Outlet <br />a <br />167-3 <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: �X S iA� <br />Conv <br />K Aggregate <br />❑ IGP <br />❑ Chamber <br />Model Number: <br />❑ AG <br />❑ Yes ❑ No <br />❑ Mound <br />o Other <br />X Pressure Systems Only <br />Header/ Manifold <br />Distribution Pipe(s) <br />X Hole Size ; X Hole <br />Qbservation Pipes <br />Length Dia <br />Length Dia Spac <br />1 Spacing <br />Yes ❑ No <br />SOIL COVER <br />Depth Over <br />Depth Over <br />Depth of <br />Seeded/ Sodded <br />Mulched <br />Cell Center <br />Cell Edges <br />Topsoil❑q <br />2 No <br />❑ Yes ❑ No <br />COMMENTS: (cludde code discrepancies, persons present, etc.) <br />Elevations taken with OAde Ko�S o`M <br />Filter Manufacturer: SAS ec� <br />M d l <br />O e. <br />Electrician: <br />(Field directive given to plumber that all electric/Wring when necessary to b completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />I <br />Plan revision required?❑ Yes No s 3 1 g Ai(5833 <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />SRIF-R71n !R 41141 <br />