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N <br />�SPs <br />Safety and Buildings Division <br />GENERAL INFORMATION <br />PRIVATE ONSITE WASTE TREATMENT <br />SYSTEMS <br />(POWTS) <br />INSPECTION REPORT <br />(ATTACH TO PERMIT) <br />rersonai mtormatton you proviae may oe usea for seconaary purposes t rnvacy Law, s. t.).u4 t t xm) I <br />Permit Holder's dame: ❑ City ❑ Village Town of: <br />", r lve rn A e <br />Insp BM Elev: BM Description: <br />�,* 4a� <br />TANK INFORMATION <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />{,C 4—> <br />Z o oD <br />Dosing <br />Aeration <br />Holding <br />TANK SETBACK INFORMATION <br />TANK TO <br />P/L <br />WELL <br />BLDG <br />VENT <br />AIRINTATA KE <br />AIR <br />ROAD <br />Septic <br />NA <br />Dosing <br />NA <br />Aeration <br />NA <br />Holding <br />PUMP / SIPHON INFORMATION <br />Manufacturer <br />mand <br />GPM <br />Model Number <br />TDH <br />Friction Loss <br />ys Head <br />TDH Ft <br />rcemain <br />L <br />I Dia <br />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 />Waters <br />--"CELL TO <br />DISTRIBUTION SYSTEM <br />County: Burnett <br />1 to S� S. <br />/e/)i/) .5 <br />Address: <br />Sanitary Permit No: <br />/9 ---37 <br />State Plan Transaction ID#: <br />Parcel Tax No: <br />G 0 9 `/ <br />ELEVATION DATA <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />Bldg. Sewer <br />s, zv <br />tcv. <br />St/HtInlet <br />S.3Y <br />gyp. <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 />& 4c,p <br />f. H % <br />Type of System <br />Distribution Media <br />Manufacturer: <br />❑ Conv <br />❑ 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 />ution Pi <br />Hole Size I X Hole <br />Observation =Pipes <br />eng Dia <br />Length Dia <br />, pacing ._._` <br />❑ Yes "6 No <br />SOIL COVER t D a4APd at'-'i'tAc p � r'ns <br />Depth Over Depth Over Depth of Seeded / Sodded Mulched <br />Cell Center Cell Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br />COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with <br />Filter Manufacturer: _ <br />Model: <br />Electrician: <br />(Field directive given to plumber that all electriciwiring when necessary to begompleted by electrician per WI Admin Code.) ❑ Yes ❑ No <br />Plan revision required?❑ YesXNo 1f G `� <br />Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />SBD-6710 (R.4/14) <br />