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PRIVATE ONSITE WASTE TREATMENT <br />y ios SYSTEMS <br />Ps (POWTS) <br />INSPECTION REPORT <br />Safety and Buildings Division (ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />rersonai mronnauon you provrae may De usea ror seconaary purposes t rnvacy Law, s. 1 D.u4 (r )(m) j <br />Permit Holder's Name: ❑ City ❑ Village 5QTown of: <br />Insp BM Elev: BM Description: <br />cdyw y- of' <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />jig r <br />1000 <br />Dosing <br />Wie-5Cr <br />(000 <br />Aeration <br />Holding <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />VENTTO <br />AIR INTAKE <br />ROAD <br />Septic <br />�5' <br />>25 <br />o2P, <br />40 <br />NA <br />Dosing <br />NA <br />Aeration <br />NA <br />Holding <br />PUMP / SIPHON INFORMATION Sct aWkWHIM. <br />Manufacturer <br />Demand <br />GPM <br />Model Number <br />TDH Lift <br />Friction Loss <br />Sys Head <br />TDH Ft <br />Forcemain <br />I L 95' <br />Dia a" <br />1 Dist. To Well <br />DISPERSAL CELL INFORMATION <br />DIMENSIONS <br />W <br />L <br /># of Cells A <br />SETBACK <br />P / L <br />Bldg <br />Well <br />OHWM of Nav <br />INFORMATION <br />Waters <br />CELL TO <br />5' <br />-550' <br />1&11NI-11�NI] 1R F&Ii , <br />County: Burnett <br />Address: ;.q (05 <br />Sanitary Permit No: <br />SW - lg-84 <br />State Plan Transaction ID#: <br />Parcel Tax No: <br />g353 <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />X 10" <br />10,2, 3 q <br />Bldg. Sewer <br />10. 33 <br />t0, 41, <br />51 <br />St/HtInlet <br />(0.(0:- <br />j0' a" <br />4 <br />St / Ht Outlet <br />10 ,q2 <br />t0' 11' <br />ql. 9 a <br />Dt Inlet <br />Dt Bottom <br />15.25 <br />IS' 3" <br />$T. 59 <br />Installation <br />Contour <br />Header / Man. <br />245 <br />41 (v � <br />9$ , 31� <br />Dist, Pipe <br />Infiltrative <br />Surface <br />5. 33 <br />� �' <br />9%. �I <br />Final Grade <br />41 <br />Top of lid <br />Type of System Distribution Media Manufacturer: <br />❑ Conv ❑ Aggregate TJAt i�-mko r <br />❑ IGP ❑ Chamber Model Number: <br />❑ AG ❑ EZFIow <br />❑ Mound ❑ Other Q - X4 <br />X Pressure Systems Only <br />H ader / Mani <br />Di ribution P <br />X Hole Size X Hole <br />Observation Pipes <br />Lengt Dia <br />Length Dia Spac <br />pacing <br />es <br />SOIL COVER vim4 covercd ott 4tw..c of A450ccfiovl <br />Depth Over <br />I Depth Over <br />Depth of <br />Seeded / Sodded <br />Mulched <br />1 <br />Cell Center <br />I Cell Edges <br />Topsoil <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with <br />{aCleo� pex altmc eof Plat. <br />Filter Manufacturer: <br />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 />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 />