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PRIVATE ONSITE WASTE TREATMENT <br />SYSTEMS <br />(POWTS) <br />INSPECTION REPORT <br />Safety and Buildings Division (ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />Personal information you provide may be used for secondary purposes [ Privacy law, s. 15.04 (1 xm) I <br />Permit Holder's Name: <br />0 City 0 Village Town of: <br />Greg //aAni <br />.vio�✓ <br />Insp BM Elev: <br />BM Description: <br />. /001no <br />IvIA,,Z .N �aee <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />j —e5 e r^ <br />jJ <br />Dosing <br />Sao` <br />7o�s <br />Aeration <br />L I <br />NA <br />Holding <br />Waters <br />CELL TO <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />AIRINTAKE <br />AIR <br />ROAD <br />Septic <br />Sao` <br />7o�s <br />— <br />L I <br />NA <br />Dosing <br />Waters <br />CELL TO <br />7 <br />NA <br />Aeration <br />lea ?0 <br />St/kit Inlet <br />3%'' <br />NA <br />Holding <br />St/ hlt Outlet <br />" <br />o S$ <br />/06225- <br />PUMP / SIPHON INFORMATION <br />Manufacturer <br />W 3' <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 I <br />Dia <br />I Dist. To Well <br />DISPERSAL CELL INFORMATION <br />DIMENSIONS <br />W 3' <br />L /a 8' <br /># of Cells,-2- <br />ellsaSETBACK <br />SETBACK <br />P / L <br />Bldg <br />Well <br />OHWM of Nav <br />INFORMATION <br />Waters <br />CELL TO <br />7 <br />DISTRIBUTION SYSTEM <br />County: Burnett <br />-9-a 79 /3y <br />Address: C V! y <br />Sanitary Permit No: <br />�aa�9y dsia3 <br />ASV- Z 7- d �J8 <br />State Plan Transaction ID#: <br />/Z/— /4, <br />Parcel Tax No: <br />07- p3& -,1-qo /7- <br />0s'- 00/-6N000 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark + <br />3,33 <br />/60.00 <br />Bldg. Sewer <br />lea ?0 <br />St/kit Inlet <br />3%'' <br />3. D <br />/D0. <br />St/ hlt Outlet <br />" <br />o S$ <br />/06225- <br />Dt Inlet <br />Dt Bottom <br />Installation <br />Contour <br />Header / Man. <br />Dist. Pipe <br />Infiltrative <br />Surface <br />/ .y,, <br />(,7 <br />6.3 3 <br />7,D0 <br />Final Grade <br />Top of lid <br />Type of System Distribution Media Manufacturer: <br />Conv ❑ Aggregate ,X J.Z A�o✓ <br />❑ IGP Chamber Model Number: <br />❑ AG ❑ EZFlow <br />❑ Mound , ❑ Other QO;ek ys�G�S <br />X Pressure Systems Only <br />Header/ Manifold <br />Distribution Pipe(s) <br />X Hole Size <br />X Hole <br />40servation Pipes <br />Length Dia <br />Length Dia Spac <br />Spacing <br />Of Yes ❑ No <br />SOIL COVER <br />Depth Over Depth Over Depth of Seeded / Sodded Mulched <br />Cell Center I Cell Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with i -SAG <br />Filter Manufacturer: <br />Model: <br />Electrician: <br />(Field directive given to plumber that all electriGwiring wh necessary t be completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />Plan revision required?❑ Yes 7 No ; F <br />Ig' a 0833 <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />SB0-6710 (R.4114) <br />