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PRIVATE ONSITE WASTE TREATMENT <br /> ,r County: Burnett <br /> /x(t p' <br /> SYSTEMS <br /> ( POWTS) <br /> `�� <br /> Safety and Buildings Division INSPECTION REPORT Address:(ATTACH TO PERMIT) - <br /> Sanitary Permit No: <br /> GENERAL INFORMATION / <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)] <br /> --PermitEol er�sNar e: ❑City ❑ Vilia e Pq To of: State Plan Transaction lD#: <br /> 71nspBM Elev: BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic (,��`� _ -2 crZv1W Benchmark Z�jr Jot. <br /> Dosing <br /> Aeration Bldg,Sewer "7. 8 yy.L <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION H-FD 4 I . St/Ht outlet <br /> TANK TO P/L WELL BLDG AIR I NTA TA KE ROAD Dt Inlet <br /> AIR I <br /> Septic ��/_ �zr p!� - NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Final Grade <br /> Model Number GPM <br /> TDH Friction oss -Sys Head TDH Ft <br /> rcemain L Dia Dist.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cell Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav ❑ Conv ❑ Aggregate <br /> Bld Well ❑ IGP ❑ Chamber <br /> INFORMATIO Waters ❑ ow Model Number: <br /> - - __ ❑- A <br /> LL TO M ❑ Other <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size Observation Pipes <br /> Spacing e <br /> SOIL COVER __— <br /> Depth Over Depth Over De Seeded/Sodded Mulched <br /> OetFOent�— a Edges Topsoil IC -- <br /> COMMENTS: (Include code discrepancies, persons present, etc.) Elevations taken with <br /> At 41 1 Cow y74y Filter Manufacture Model: <br /> ,/4'L0�Aa d y Electrician: <br /> (Field directive given to plumber that all electric/wiring when necessary to be c mpleted by electrician per WI Admin Code.) ❑Yes El No <br /> Plan revision required?[] Yes❑No -I <br /> /� Fze-) w 1 & <br /> Use other side for additional information Date POWTS Inspector's Signature Certification Number <br />