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X.p <br />P i. <br />Safety and Buildings Division <br />PRIVATE ONSITE WASTE TREATMENT <br />SYSTEMS <br />(POWTS) <br />INSPECTION REPORT <br />(ATTACH TO PERMIT) <br />GENERAL INFORMATION of 1 r -\KN tj Q);- Y -)s <br />Personal information you provide may be used for secondary purposes r Privacv Law. s. 15.040)1 <br />Permit Holder's Name: <br />MANUFACTURER <br />❑ City ❑ Village own of: <br />1 <br />.D Q� Tl O A �� �S d ar rJ�— <br />AIR I <br />AIRI TONTAKE <br />I <br />QQ ! O ✓1 �` <br />Insp BM Elev: <br />BM ge cription: <br />Holding <br />) (3d . O a <br />8 o4�0 r" <br />--IF J lyn <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />Dosing <br />AIR I <br />AIRI TONTAKE <br />ROAD <br />Aeration <br />77, <br />Holding <br />l e S <br />SOD Z, <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />AIR I <br />AIRI TONTAKE <br />ROAD <br />Septic <br />Sys Head <br />TDH Ft <br />Forcemain <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 />7 a <br />7 a 5 <br />7 5 <br />A/ j1 <br />Q <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 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 />Waters <br />CELL TO <br />Bldg. Sewer <br />DISTRIBUTION SYSTEM <br />County: Burnett <br />F <br />a? 33 1 E Oev,) s i -o, <br />Address: 1Q0 <br />Sanitary Permit No: 0 <br />SAA/ - I% <br />-yam <br />State Plan Transaction ID#: <br />Tax No: <br />1397 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />3 %6 <br />103.76 <br />Bldg. Sewer <br />St/Ht Inlet <br />5.67 <br />9$,09 <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 />Type of System Distribution Media Manufacturer: <br />❑ Conv ❑ Aggregate Ha) 1 &VIII, <br />❑ IGP ❑ Chamber <br />❑ AG ❑ EZFlow Model Numbe : <br />❑ Mound ❑ Other <br />X Pressure Systems Only <br />H/ Manifold <br />Distribution Pipe(s) <br />Xeader Hole Size ; X Hole <br />Observation Pipes <br />Length Dia <br />Length Dia Spac <br />I Spacing <br />❑ Yes ❑ No <br />SOIL COVER <br />Depth Over <br />Depth Over Depth of <br />Seeded/ Sodded <br />Mulched <br />Cell Center <br />Cell Edges Topsoil <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with <br />filter Manufacturer: <br />Model: <br />Electrician: T� l �l <br />(Field directive given to plumber that all electric/Wring when necessary to be completed by electrician per WI Admin Code.) ❑ Yes NO <br />Plan revision required?❑ Yeso No 6 ) Dr 3 15 32-5 <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />SBD -6710 (R 4/14) <br />