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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Bumett County <br /> NVisconsin ( POWTS) Property Address:,US/C� <br /> Department of Commerce INSPECTION REPORT , O <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION C <br /> Personal information you provide may be used for secondary pu ses[Privacy Law,s. 15.04(1 xm)) <br /> P � Holder's Name: y� El City Village Town of: State Plan/Transaction ID#: <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark X. co /OZ pp /OD. Oo <br /> Dosing <br /> Aeration Bldg.Sewer 570 41ila,90 <br /> Holding W I�-:659- WI—t' 9 0 00 v llo� St/Ht Inlet 6 Z5 9S75 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding 50'+ Dist Pipe <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <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 No of Cells Type of System Manufacturer: <br /> SETBACK OHWM of Nav REpL.Acr6 M6NT- LEACHING <br /> INFORMATION P/L Bldg well Waters 14 o-tl)NG CHAMBER Model Number: <br /> CELL TO I <br /> A K I-'— <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac 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? ON <br /> Schedule 40 Vents and Observation Pipes?& N <br /> Cover Material: ,r/Z4 <br /> Effluent Filter Manufacturer /0 4 Model Nl i <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No r0� "M�nj� Fd7 11rA" d 1 <br /> Use other side for additional information Date PO nspector's Signatur Cert No <br />