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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> NVisconsin ( POWTS) Property Address:3yc' <br /> uepartment of Commerce INSPECTION REPORT a <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide may be used for secondary purposes I Privacy Law,s. 15.04(1 Xm)I L I"► <br /> Permit Holder's Name: 0 City U Village own of: State Plan Transaction ID#: <br /> c e a <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> AIAIL IA.) �6fD dI A4 4Z <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic j/ W900 o Benchmark 3.3D )03- 30 co,va <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet 7 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >75 N/>t -'25, NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. 3100S <br /> Holding Dist. Pipe <br /> PUMP 1 SIPHON INFORMATION Infiltrative <br /> Surface _9L740,6 <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 2, Type of System Manufacturer: <br /> SETBACK <br /> Conveh�+onHl LEACHING <br /> P/L Bldg well Waters <br /> of Nav CHAMBER <br /> INFORMATION Waters _Ln-_ ,,�n� Model Number: <br /> CELL TO > 5 %45' /✓/A x (b <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.) f? ism -6 Tc,Jv t3j50/10&,K .5 T��t t <br /> Permit Posted? & N <br /> Schedule 40 Vents and Observation Pipes? Y) N <br /> Cover Material- 71YAL <br /> Effluent Filter Manufacturer �Al'�EL Model A- 1S00 <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No �� ��►' ` <br /> Use other side for additional information Date POWTS Inspector's Signature Cert No <br />