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y los �. <br /><,,P <br />Safety and Buildings Division <br />PRIVATE ONSITE WASTE TREATMENT <br />SYSTEMS <br />(POWTS) <br />INSPECTION REPORT <br />(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 L3 Village l� Town of: <br />/Yi/yl'0. Q7GG.Y0W/G2 <br />Ga1OIle 1�41t <br />Insp BM Elev: <br />BM Description: <br />/00.0,9 <br />B11,0N <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />AIRI TONTAKE <br />AIR I <br />ROAD <br />Dosing <br />Sys Head <br />TDH Ft <br />Aeration <br />L I <br />NA <br />Holding <br />6 ywe S G <br />X 1960 = a 000 <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />AIRI TONTAKE <br />AIR I <br />ROAD <br />Septic <br />Sys Head <br />TDH Ft <br />Forcemain <br />L I <br />NA <br />Dosing <br />Waters <br />CELL TO <br />9S—, 7T <br />I/ Ht Inlet <br />NA <br />Aeration <br />9saa <br />Pf / Ht Outlet <br />NA <br />Holding <br />7/0' <br />7,08 <br />9-11- 9Z/ <br />Dt Bottom <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 I <br />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 />❑ EZFlow <br />Bldg. Sewer <br />Waters <br />CELL TO <br />9S—, 7T <br />I/ Ht Inlet <br />70 <br />DISTRIBUTION SYSTEM <br />County: Burnett X <br />�/t ay70/1 mg 3a <br />G <br />Address: a r ri d e -e Su U & <br />Sanitary Permit No: CPQ 93 7a <br />SAti-/9-/7 <br />State Plan Transaction ID#: <br />NIq <br />Parcel Tax No: <br />07- o/y-a -38-/s os -s <br />ya7- 0/Y000 <br />ELEVATION DATA <br />STATION BS <br />HI <br />FS <br />ELEV <br />Benchmark , <br />/D/.9� <br />❑ Chamber <br />/00,00 <br />Model Number: <br />❑ AG <br />❑ EZFlow <br />Bldg. Sewer <br />❑ Other <br />9S—, 7T <br />I/ Ht Inlet <br />70 <br />9saa <br />Pf / Ht Outlet <br />9-11,97 <br />�T 2 Lef cfJQs <br />ISN <br />7,08 <br />9-11- 9Z/ <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 <br />Distribution Media <br />Manufacturer: <br />❑ Conv <br />❑ Aggregate <br />❑ IGP <br />❑ Chamber <br />❑ Yes ❑ No <br />Model Number: <br />❑ AG <br />❑ EZFlow <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 />I Spacing <br />❑ Yes ❑ No <br />SOIL COVER <br />Depth Over Depth Over Depth of Seeded I Sodded Mulched <br />Cell Center Cell Edges Topsoil I ❑Aes 0 No_ ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with <br />Filter Manufacturer: <br />Model: <br />Electrician: <br />(Field directivgiven to plumber that all electric/Wring when necessary to be completed by electrician per WI Admin Code.) 11 Yes ❑ No <br />l <br />Plan revision required?❑ Yes No <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />