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PRIVATE ONSITE WASTE TREATMENT <br /> " os I'; SYSTEMS County: Burnett <br /> Ps ( POWTS) <br /> w INSPECTION REPORT 25543 A/. DwAc Rd. <br /> R.1SIf)���w <br /> Safety and Buildings Division Address:, <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit NoN, !: '10 <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] <br /> Permit Holder's Name: ❑City ❑ Village wn of: State Plan Transaction ID#: <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> 1 <br /> l 0 f� 0� P � I i°►31 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic :K20 Benchmark <br /> Zb ►03. 20IL <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 30 <br /> q7.qo <br /> TANK SETBACK INFORMATION St/HtOutlet <br /> TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >a5' to, A16' 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 g� <br /> Manufa turer Demand Final Grade 3.40 qq. $0 <br /> Mod Number GPM <br /> TD Li iction Loss Sys Hea TDH <br /> Forcemain L I Dia ell Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W L ' #of Cells f Type of System Distribution Media Manufacturer: <br /> SETBACK OHWM of Nav � Conv ❑ Aggregate l�yl�t� C�-�►� <br /> INFORMATION P/L Bldg Well Waters ❑ IGP ❑ Chamber <br /> ❑ AG EZFIow Model Number: <br /> CELL TO >Ib` Z51 5o, ❑ Mound ❑ Other 3 x Ia` <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> H ader/Manifold e s �XHole Size I Obs� eervation Pipes <br /> Le Length Dia Spac i Spacing es Cl I <br /> SOIL COVER of c6ver a-F wtL aF itts CC a✓1 <br /> Depth Over Depth Over Depth f _ Seeded/ d Mul <br /> Cell Center Cell Edges TopsoilF ❑No s ❑No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with Wy/ji& �kkl a-0-,wLk6r <br /> rK5,I tVed per aibt,,e p?w Filter Manufacturer: P <br /> ehaztrd 40 61)' ;nskaC( o�- 0' Model: <br /> Electrician: <br /> (Field directive given to plumber that all electric/wiri hen necessary to beppmpleted by electrician per WI Admin Code.) ❑Yes❑No <br /> Plan revision required?❑Yes 9-Ne <br /> Use other side for additional information Date POWTS ln6ldcto Signature Certification Number <br />