Laserfiche WebLink
PRIVATE ONSITE WASTE TREATMENT <br />y `nS SYSTEMS <br />'S (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)(m) ] <br />Permit Holder's Name: <br />❑ City ❑ Village Town of: <br />X / A1141 �v t 9-t lw ,q� <br />Septic <br />Insp BM Elev: <br />BM Description: <br />%D, Db <br />boAll, o Sid.'n^g owi�e�r <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />VENT TO <br />AIR INTAKE <br />ROAD <br />Dosing <br />Sys Head <br />TDH Ft <br />Forcemain <br />X' ;1V <br />76-0 .. <br />Holding <br />a-NOrw�s�o /000 1 <br />19.000� <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />VENT TO <br />AIR INTAKE <br />ROAD <br />Septic <br />Sys Head <br />TDH Ft <br />Forcemain <br />L <br />NA <br />Dosing <br />Aeration <br />Waters <br />CELL TO <br />Bldg. Sewer <br />NA <br />NA <br />Holding <br />St / Ht Inlet <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 />I Dia <br />I 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 />❑ EZFIow <br />❑ Mound <br />Waters <br />CELL TO <br />Bldg. Sewer <br />DISTRIBUTION SYSTEM <br />County: Burnett <br />-: 0 77 gan fr <br />Address:/— <br />Sanitary Permit No: &0a N3 <br />6, N- / $— <br />State Plan Transaction ID#: <br />A14 — <br />Parcel Tax No: <br />07-o <br />Dy-ODD-D/3f�Do <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />Sb <br />/0/, So <br />Model Number: <br />/DD,a <br />❑ EZFIow <br />❑ Mound <br />❑ Other <br />Bldg. Sewer <br />St / Ht Inlet <br />CW Ht Outlet <br />/ <br />x; s <br />76-o Wc P <br />6 <br />:11/ iJo�wes6o <br />IAAtiLt�// <br />Ile9ysy <br />7,/7 <br />33 <br />Header / Man. <br />Dist. Pipe <br />Infiltrative <br />Surface <br />Final Grade <br />Top of lid <br />Type of System <br />Distribution Media <br />Manufacturer: <br />❑ Conv <br />❑ Aggregate <br />❑ IGP <br />❑ Chamber <br />[]Yes ❑ No <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 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 <br />Cell Center Cell Ed4es Toosoil <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with <br />Seeded / Sodded Mulched <br />Q Yes ❑ No ❑ Yes ❑ No <br />vfS�oLm <br />Filter Manufacturer: <br />Model: <br />Electrician: <br />(Field directive given to plumber that all electric/wiring whe necessary tobe completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />Plan revision required?❑ YesA No 7 �oZ %8 a2aZ 083,3 <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />