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®v PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> isconsin ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) W6 T' P OIN 7- t�V) <br /> GENERAL INFORMATION Sanitary Permit No: <br /> Personal information you provide may be used for second u oses Privacy Law,s. 15.04(1)(m) "t 3B 307 <br /> Permit Holder's Name: _: <br /> State Plan Transaction ID#: <br /> Df�L� r!71nsp <br /> Ol Town of: 5C0!T- <br /> CST BM Elev: BM Elev: BM Description: Parcel Tax No: <br /> /oo. 00 SAMe. 1�AIL_ /aJ 3D l�uE b28 �/25 05 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE I MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark <br /> 2.16 /o,Z./(o /l.O.CC <br /> Dosing <br /> Aeration Bldg. Sewer 470 <br /> Holding St/Ht Inlet 'A 9Z <br /> TANK SETBACK INFORMATION St/Ht Outlet 5.0 97.D <br /> TANK TO P/L WELL BLDG AIR INTA TAKE ROAD Dt Inlet <br /> AIR <br /> Septic >50 -%39 /4- — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist. Pipe 647-6,77 96.'f9 .39 <br /> PUMP/SIPHON INFORMATION System 6.50 <br /> Elevation 7&19 949 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> Lift Fr. Loss Head TDH <br /> Forcemain Length Dia Dist/Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width Co Length SD :N1.,Cje1lsjL Type of System Manufacturer: <br /> SETBACK fNav „ �rr,a,l LEACHING <br /> INFORMATION P/L Bldg CHAMBER Model Number: <br /> CELL TO /g 25` 9 <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Ob ervation Pipes <br /> Length — Dia Length� Dia u Spac - Spacing Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges To soil ❑Yes ❑No ❑Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Components Not Inspected <br /> er Permit Posted Cover Material PAk- <br /> sr Warning labels on manhole covers w/locks <br /> ar Schedule 40 Vent Material <br /> a-� Effluent Filter installed Model A "180o M <br /> Plan revision required?❑Yes❑ No )(J O3 7 FO 3 ' <br /> Use other side for additional information Date PO WT spector's Signatu Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R 3/01 ) <br />