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PRIVATE ONSITE WASTE TREATMENT <br /> fs County: Burnett <br /> _ DS :`, SYSTEMS Z99/s eAAA,6emy Le, <br /> S ' ( POWTS) <br /> INSPECTION REPORT Address: <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 0-7 V <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1 xm) <br /> Permit Holder's Name: ❑City Village [A Town of: State Plan Transaction ID#: <br /> L4,vLc-o— 7F,t,-Ys .S�lis s <br /> Insp BM Elev: E M Description: Parcel Tax No: <br /> z z5S 9 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic �tJ�p e n o o Benchmark 3.r>t /D Ail <br /> Dosing <br /> Aeration Bldg.Sewer $-7 `.-7/ <br /> Holding St/Ht Inlet 70 <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANK TO P/L WELL BLDG VENT To ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic D(,< '7.r zD NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. 7.5-- 96.D$ <br /> Holding Dist. Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative -7. 5' 9578' <br /> Surface <br /> Manufacturer D Final Grade <br /> Model Number GPM <br /> TDH riction oss ead TDH Ft <br /> emain L Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION / <br /> DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav Conv ❑ Aggregate <br /> INFORMATION P/L Bldg Well Waters IGP AG o Chamber Model Number: <br /> ❑ X EZFIow <br /> CELL TO p 1( 2/ "7-0-b psa ❑ Mound ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Dist rib �,IIXl Observation Piing es ❑N oL <br /> SOIL COVER <br /> Depth Over Depth Over epth of S ulch <br /> C I er Cel ges Tc , ❑Yes ❑No , ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) Elevations taken with <br /> Filter Manufacturer: /,'re�I A <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 /> i <br /> Plan revision required?❑ Yes M No �, � le, /9 F�j— <br /> , �y( $ & I / X <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />