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Y, SSP I <br />s . <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)(1n) ] <br />Permit Holder's Name:/ <br />MANUFACTURER <br />❑ Village Town of: <br />�i rn -. p h n/ S50't, <br />AIR I <br />AIRI NTATA KE <br />=�,9,yoal <br />Insp BM Elev:BM�Description: <br />W <br />,Q / <br />�Nl /; e -0'r' �Q�i3t"iN� <br />/0,0,00/o� <br />L alp' <br />NA <br />Holding <br />m <br />ri' <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />AIR I <br />AIRI NTATA KE <br />g'y p <br />Dosing <br />>>o <br />00 <br />Aeration Aeration <br />L alp' <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 I <br />AIRI NTATA KE <br />ROAD <br />Septic <br />>>o <br />'$o' <br />7/o ' <br />L alp' <br />NA <br />Dosing <br />Waters <br />CELL TO <br />Bldg. Sewer <br />NA <br />Aeration <br />9y.S1 <br />St / Ht Inlet <br />NA <br />Holding <br />St / Ht Outlet <br />PUMP / SIPHON INFORMATION <br />Manufacturer <br />S ati <br />Demand <br />GPM <br />Model Number <br />30 <br />TDH ` ' Lift <br />Friction Loss .4 <br />Sys Head <br />TDH/p,oy Ft <br />Forcemain <br />L alp' <br />I Dia X' <br />I Dist. To Well <br />DISPERSAL CELL INFORMATION <br />DIMENSIONS <br />W <br />L <br /># of Cells <br />SETBACK <br />P / L <br />Bldg <br />Well <br />OHWM of Nav <br />INFORMATION <br />❑ Mound <br />❑ Other <br />Waters <br />CELL TO <br />Bldg. Sewer <br />g-Oq <br />DISTRIBUTION SYSTEM <br />County: Burnett <br />/08/-111 <br />Address: Zee/' <br />Sanitary Permit No: 6097Ny <br />N- 18"- 440 <br />State Plan Transaction ID##: <br />Parcel Tax No: s os --008-0010000 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />, (n p <br />�Qa , (p� <br />❑ AG <br />100.00 <br />❑ Mound <br />❑ Other <br />Bldg. Sewer <br />g-Oq <br />9y.S1 <br />St / Ht Inlet <br />$• A <br />9q, 3d <br />St / Ht Outlet <br />Dt Inlet <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 />erAilrAv <br />K Conv <br />V, Aggregate <br />❑ IGP <br />❑ Chamber <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 I X Hole <br />bservation Pipes <br />Length Dia <br />Length Dia Spac <br />I Spacing <br />g3 Yes ❑ No <br />SOIL COVER " <br />Depth Over <br />Depth Over <br />Depth of <br />Seeded / Sodded <br />Mulched <br />Cell Center <br />Cell Edges <br />I Topsoil <br />L ❑ Y s No <br />❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations takeni� Xv�s <br />�C Filter Manufacturer: <br />le 1 <br />a q 2ivsl-e4�'JOV' Model: <br />Electrician: <br />(Field directive given to plumber that all electriclwiring wh�el necessarylo be completed by electrician per WI Admin Code.) ❑ Yes ❑ No <br />I <br />Plan revision required?❑ Yes 4 N s— �L7/Le <br />a a 08'33 <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />SRr1_R710 /R A11d1 <br />