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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 nrovide may be used for secondary numoses f Privacv Law. s. 15.04 (I)(m) 1 <br />Permit Hojder's Name: <br />❑ City ❑ Village IF Town of: <br />///r() 1v Goo <br />/�% e,, y,o <br />Insp BM Elev: <br />BM Description: <br />goo, <br />Sys Head <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />AIR I <br />AIRI NTATA KE <br />ROAD <br />Dosing <br />Sys Head <br />TDH Ft <br />Aeration <br />L <br />NA <br />Holding <br />jeSef 3G�8 <br />CELL TO <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />AIR I <br />AIRI NTATA KE <br />ROAD <br />Septic <br />Sys Head <br />TDH Ft <br />Forcemain <br />L <br />NA <br />Dosing <br />Waters <br />CELL TO <br />A/ Ht Outlet <br />7 aZ 1 <br />NA <br />Aeration <br />Dt Bottom <br />NA <br />Holding <br />.S <br />> S <br />a a <br />PUMP 1 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 />S47 <br />I Dist. To Well <br />t,9»:by1�9i:1111IRR174]:'1&F-INIiIQ <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 />-1-00 <br />S47 <br />Alt / Ht Inlet <br />Waters <br />CELL TO <br />A/ Ht Outlet <br />7 aZ 1 <br />100.0 <br />Dt Inlet <br />DISTRIBUTION SYSTEM <br />EL <br />County: Burnett <br />%Do20 <br />Address: s. ,Je'as /Kd . <br />Sanitary Permit No: /„O aV <br />S" /7- s - yr <br />State Plan Transaction ID#: <br />Parcel Tax No: <br />o7-oi8-a 39- 6 -o3 -s <br />O S -OD 3 - 4a %OOIi <br />EVATION DATA <br />STATION BS HI <br />FS <br />ELEV <br />Benchmark 7 97 <br />❑ Aggregate <br />/00.00 <br />❑ Chamber <br />Model Number: <br />Bldg. Sewer <br />-1-00 <br />S47 <br />Alt / Ht Inlet <br />7.09 <br />/00.1 <br />A/ Ht Outlet <br />7 aZ 1 <br />100.0 <br />Dt Inlet <br />Dt Bottom <br />Installation <br />Contour <br />Header/ Man. <br />Dist. Pipe <br />Infiltrative <br />Surface <br />Final Grade <br />W1W oA-' <br />Top of lid a,VG' -A er 1, 4AI <br />-7 <br />1/00.00 <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 />❑ 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 />❑ Yes ❑ No <br />SOIL COVER <br />Depth Over Depth Over Depth of Seeded/ Sodded Mulched <br />Cell Center Cell Edoes Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with JOAN 5 j%± '0 CA <br />1/,Va/Filter Manufacturer: <br />Model: <br />sPs 3�a-°D <br />Ge,,mal PZ,,�k, �, Electrician: <br />(Field directive given to plumber that all electric/vMAring en necess to be completed by electrician per WI Admin Code.) ❑ Ye No <br />Plan revision required?❑ Yes t No / S t� J� / It 9,? <br />rtli <br />Use other side for additional information ur Date 6 POWTS Inspector's Signature Cefication Number <br />SBD -6710 (R.4/14) <br />