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PRIVATE ONSITE WASTE TREATMENT <br />Y 4'oS SYSTEMS <br />P (POWTS) <br />INSPECTION REPORT <br />Safety and Buildings Division (ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />Personal ;nfnrmar;nn vnp provide may he used for secondary Purposes f Privacy Law, s. 15.04 (1)(m) ] <br />..,..,.,..... ----"-----'--.- I -- - - -- - - <br />'s Name: <br />Permit HAarKA)e SS <br />- <br />❑ City ❑ Village Town of: <br />Ja A'so,v <br />Insp BM Elev: <br />d <br />BM Description: <br />�s�Oha L� <br />/�� • � <br />� o �' <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />0 we st p <br />/040 <br />Dosing <br />Sys Head <br />.7 S'� <br />Aeration <br />I 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 />Sys Head <br />.7 S'� <br />/8 <br />I L <br />NA <br />Dosing <br />Aeration <br />Waters <br />CELL TO <br />Bldg. Sewer <br />NA <br />NA <br />Holding <br />, Is - <br />St / Ht Inlet <br />y 3.1, <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 />I L <br />Dia I <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 Nav <br />INFORMATION <br />❑ Chamber <br />Model Number: <br />Waters <br />CELL TO <br />Bldg. Sewer <br />❑ Mound <br />, a / <br />County: Burnett <br />Address: 1, Lala e r <br />Sanitary Permit No: <br />State Plan Transaction ID#: <br />.VW — <br />Parcel Tax No: /3 - <br />S- 16--1,4V —4-5-74"'0 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />, Z <br />/m, 3 <br />/00.06 <br />❑ Chamber <br />Model Number: <br />❑ AG <br />❑ EZFIow <br />Bldg. Sewer <br />❑ Mound <br />, a / <br />, Is - <br />St / Ht Inlet <br />y 3.1, <br />916, Oq <br />St / Ht Outlet <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 />DISTRIBUTION SYSTEM X Pressure Systems Only <br />Header / Manifold Distribution Pipe(s) X Hole Size ; X Hole servation Pipes <br />Length Dia Length Dia Spac j Spacing Yes ❑ No <br />SOIL COVER <br />Depth Over Depth Over Depth of Seeded / Sodded Mulched <br />Cell Center Cell Edges Topsoil _ ❑ Y s No ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken <br />// S� /� �� / Filter Manufacturer: c <br />Caee A07 n•'L e oe L 1;,v �/L� . Model: <br />Electrician: <br />(Field directive given to plumber that all electric/wiring en ec ssary t e completed by electrician per WI Admin Code.) ❑ Yeo <br />I <br />Plan revision required?❑ YesNo � ) C<Vj a �-6w <br />! a a�I 3 <br />Use other side for additional inf mation Date POWTS Inspector's Signature Certification Number <br />Type of System <br />Distribution Media <br />Manufacturer: <br />Conv <br />Aggregate <br />❑ IGP <br />❑ Chamber <br />Model Number: <br />❑ AG <br />❑ EZFIow <br />❑ Mound <br />o Other <br />DISTRIBUTION SYSTEM X Pressure Systems Only <br />Header / Manifold Distribution Pipe(s) X Hole Size ; X Hole servation Pipes <br />Length Dia Length Dia Spac j Spacing Yes ❑ No <br />SOIL COVER <br />Depth Over Depth Over Depth of Seeded / Sodded Mulched <br />Cell Center Cell Edges Topsoil _ ❑ Y s No ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken <br />// S� /� �� / Filter Manufacturer: c <br />Caee A07 n•'L e oe L 1;,v �/L� . Model: <br />Electrician: <br />(Field directive given to plumber that all electric/wiring en ec ssary t e completed by electrician per WI Admin Code.) ❑ Yeo <br />I <br />Plan revision required?❑ YesNo � ) C<Vj a �-6w <br />! a a�I 3 <br />Use other side for additional inf mation Date POWTS Inspector's Signature Certification Number <br />