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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 />n,....., --I .,.,:AA .,, , hA „SAA f'— —mn— r Ptivary f aw c 1 5 o4 (i )(m) 1 <br />Permit Holder's Name: <br />MANUFACTURER <br />❑ City El Village Town of: <br />Z41a GG'y La P'sa ti <br />1 f i'N GiJG P <br />� a(,//s o.v <br />Insp BM Elev: <br />BM Description: <br />90 Tl <br />S� o/. i�,g► <br />Aeration <br />o M <br />NA <br />III /_1►112111111R[Vi :4►'iC\ILOW`I <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />1 f i'N GiJG P <br />/off Do <br />Dosing <br />Sys Head <br />TDH Ft <br />Aeration <br />L <br />NA <br />Holding <br />Waters <br />tear' <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />VENTTO <br />AIR INTAKE <br />ROAD <br />Septic <br />Sys Head <br />TDH Ft <br />Forcemain <br />L <br />NA <br />Dosing <br />Waters <br />tear' <br />a� f <br />NA <br />Aeration <br />St/ Ht Inlet <br />NA <br />Holding <br />St / Outlet <br />33 <br />PUMP / SIPHON INFORMATION <br />Manufacturer <br />L,' <br />Demand <br />GPM <br />Model Number <br />a8'3- 2, <br />TDH Lift <br />Friction Loss <br />Sys Head <br />TDH Ft <br />Forcemain <br />L <br />I Dist. To Well <br />1]lyJ:11ZV _119y:1NEI►11811"WIF-1111111ILei► <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 />County: Burnett <br />Sanitary Permit No: <br />State Plan Transaction ID#: <br />,rid - <br />Parcel Tax No: <br />o7-o1g-a-yo-/s-oi-s <br />os -Do y- , a; 0 <br />FL FVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />! Spacing <br />❑ Yes ❑ No <br />a ❑ Yes ❑ No <br />❑ Yes ❑ No <br />Bldg. Sewer <br />St/ Ht Inlet <br />St / Outlet <br />33 <br />Dt Inlet <br />c9 <br />91,23 <br />Dt Bottom <br />87,2 _T <br />Installation <br />Contour <br />Header / Man. <br />Dist. Pipe <br />Infiltrative <br />Surface <br />Final Grade <br />ase'/A X <br />e <br />Top of lid <br />Type of System <br />Distribution Media <br />Manufacturer: <br />�S �•N <br />❑ Conv <br />❑ IGP <br />❑ AG <br />❑ Mound <br />A,Aggregate <br />❑ Chamber <br />❑ EZFIow <br />❑ Other <br />Model Nu <br />g X 3(a <br />X Pressure Svstems Only <br />Header / Manifold <br />Distribution Pipe(s) <br />X Hole Size X Hole <br />Observation Pipes <br />Length Dia <br />Length Dia Spac <br />! Spacing <br />❑ Yes ❑ No <br />L-T6TI <■TGV1d 4 <br />Depth Over <br />Depth Over <br />Depth of <br />Seeded/ Sodded <br />Mulched <br />Cell Center <br />Cell Edges <br />Topsoil <br />a ❑ Yes ❑ No <br />❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with %io SS 70 4 L a.vole- ' / <br />P/ p // Filter Manufacturer: <br />� pGa�e 5fee� Pv.��,rv� G�arhAe,^. Model: <br />Electrician: <br />(Field directive given to plumber that all electric/Wring when necessary to be completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />i <br />Plan revision required?❑ Yes No /e <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />