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-'""�-- PRIVATE ONSITE WASTE TREATMENT <br /> y "D SYSTEMS County: Burnett <br /> s <br /> PS % ( POWTS) <br /> 4 INSPECTION REPORT Address:a%64w aat <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 6A1)- 19-IM <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(1Xm)] <br /> Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: <br /> �iv�t. ��SovL �niovk 614? IV <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> V060ylt of i �539 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Aknuesco 1000 Benchmark 2- lo2.(oa ►00 <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet 6. It (o,5 <br /> TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >15 ,Z,S JQ' 7�S 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 Demand Final Grade <br /> Model Num r GPM <br /> TDH Lift Fric' oss Sys He d Ft <br /> Forcemain L Dia Is.To Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L #of Cells F Type of System Distribution Media Manufacturer: <br /> SET CK OHW f Nav 4�L Conv 9,Aggregate — <br /> INFO ATION P/L Idg Well ,WaTers ❑° GP ❑ Chamber Model Number: <br /> ❑ EZFIow <br /> Cl Mound o Other -- <br /> DISTRIBUTION SYSTEM / X Pressure Systems Only <br /> Header/Manifold 'on Pipe(s) 1 X Hole Obsery ' <br /> Le Dia Length pac I pa Yes ❑ No <br /> SOIL COVER Alof cavercoC -�titit,C ivts c��io� <br /> Depth Over Depth Over _ Depth of Seeded/Sodded Mulched <br /> Cell Center — Cell Ed es To soil r ❑Yes ❑ No ❑Yes ❑ No <br /> COMMENTS: (Include code discrepancies,persons present, etc.) Elevations taken with <br /> sated sags Filter Manufacturer: 1,W-4eC. <br /> Model: -- <br /> $cot' wm' usa �r d�`r" `'eO� Electrician: — <br /> 0 per WI Admin Code. ❑Yes❑ No <br /> (Field directive given to plumber that all electnc/v`nri when necessary to c mpleted by electrician p ) <br /> Plan revision required?❑Yespi�o 3 �� iu$1593 <br /> Use other side for additional information Date POWT V94exr, <br /> Signature Certification Number <br />