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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Visconsin ( POWTS) Property Address:bq((O <br /> Department of Commerce INSPECTION REPORT WQ PA. <br /> safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide may be used for secon s Privacy Law, 15.04(1 m) a of <br /> Permit Holder's Name: Ell <br /> village am of: State Plan Transaction ID#: <br /> boy F��cKs� �Klard <br /> CST BM Elev: Insp BM Elev: BM D�cription: Parcel Tax No: <br /> 501VYIQ> d Na+ 11.E double 0 0-q314-0340 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ZELEVSeptic Benchmark 01. <br /> Dosing <br /> Aeration Bldg.SewerHolding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic SDI sj't 151 NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. C?q, <br /> Holding Dist Pipe q <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> 0 <br /> Model Number GPM S e 7-7 R •�� <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width / Length)Cgr No otcols Type of System Manufacturer: <br /> Colt✓, LEACHING <br /> SETBACK P/L Bldg wen waters or Nav CHAMBER <br /> INFORMATION -G�� Model Number: <br /> CELL TO >t <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) ( X Hole Size X Hole Observation Pipes <br /> Length Dia Length D ( Dia <br /> Spec <br /> Spacing ❑Yes ❑No <br /> SOIL COVER <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.) <br /> Permit Posted? Y N <br /> Schedule 40 Ven nd Ob rvation Pipes N <br /> Cover Material: OP KI - I� Gj� <br /> Effluent Filter Manufacturer Model <br /> Components Not Inspected: <br /> Plan revision required?❑Yes Ri No 'c3i\ I l✓vl 3 Ql <br /> Use other side for additional information Date POWTS/Inspector's Signature Cert No �I <br />