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PRIVATE ONSITE WASTE TREATMENT <br />( "r SYSTEMS <br />(POWTS) <br />INSPECTION REPORT <br />Safety and Buildings Division (ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />Pemmil inf—f;nn —, —'M. ,.,o., I --'—A f— tea..—A—, r D.4........ r ... 1 e nn t 1 v._1 1 <br />Permit Holder's Name- <br />;04er� <br />❑ City ;�IIlage Town of: <br />Carat <br />SC <br />Insp SM Elev: <br />BM Description: <br />/QD ' <br />4%IL I'ti /y le— <br />I/_h1:111ZIIQ NkllI!%INI►I <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />Ni -i' rA D <br />le SID <br />Dosing <br />do, <br />7o15 <br />Aeration <br />❑ EZFlow <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 <br />AIRINTAKE <br />ROAD <br />Septic <br />do, <br />7o15 <br />/S" <br />❑ EZFlow <br />NA <br />Dosing ' <br />Waters <br />CELL TO <br />Bldg. Sewer <br />NA <br />Aeration <br />St / W1 Inlet <br />NA <br />Holding <br />St / HCOutlet(o.9S, <br />7y <br />PUMP I SIPHON INFORMATION <br />Manufacturer <br />W 31 <br />Demand <br />GPM <br />Model Number <br />SETBACK <br />TDH Lift <br />Friction Loss <br />Sys Head <br />TDH Ft <br />Forcers <br />❑ EZFlow <br />I Dia <br />I Dist. To Well <br />Ili 611Ja:f.`f_1Wya101z1201:4LVIr 11101ki <br />DIMENSIONS <br />W 31 <br />L a6jg ' <br /># of Cells 3 <br />SETBACK <br />P / L <br />Bldg <br />Well <br />OHWM of Nav <br />INFORMATION <br />❑ EZFlow <br />y s <br />❑ Mound <br />Waters <br />CELL TO <br />Bldg. Sewer <br />7.50 <br />1111.111 "ki 1 :1111 If) 0 ININI1Z!J,I <br />County: Burnett <br />-xt3y6 l <br />Address: /%%C126L, (rte.✓ �.� <br />Sanitary Permit No: 66614 %v <br />SAAv- / 7 -,t 3 ;t - <br />State Plan Transaction ID#: <br />Parcel Tax No: <br />07- 8- J- - yo-iy-07- <br />s is-y8'a-oyy000 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />C21 <br />0J <br />Model Number: <br />app ,D <br />❑ EZFlow <br />y s <br />❑ Mound <br />❑ Other <br />Qa/., ,� PGv <br />Bldg. Sewer <br />St / W1 Inlet <br />St / HCOutlet(o.9S, <br />7y <br />Dt Inlet <br />Dt Bottom <br />Installation <br />Contour <br />Header/ Man. <br />% <br />5 SO <br />Dist. Pipe <br />Infiltrative <br />Surface <br />AGG 3 Ce <br />CS �� <br />Final Grade <br />Top of lid <br />Type of System <br />Distribution Media <br />Manufacturer: <br />---r— <br />jX Conv <br />❑ Aggregate <br />❑ IGP <br /># Chamber <br />QTGr <br />Model Number: <br />❑ AG <br />❑ EZFlow <br />y s <br />❑ Mound <br />❑ Other <br />Qa/., ,� PGv <br />X Praccnra ..'vCtamC 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 />I It Yes ❑ No <br />BUIL LUVLK <br />Depth Over Depth Over Depth of Seeded / Sodded Mulched <br />Cell Center Cell Edges I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with Te N S Q <br />Filter Manufacturer: GrAe /i"e <br />Model: <br />Electrician: <br />(Field directive given to plumber that all electric/wiring when necessary to be completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />hi <br />Plan revision required?❑ Yes No <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />SBD -6710 (R.4/14) <br />