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k'' PRIVATE ONSITE WASTE TREATMENT <br /> Burnett <br /> ,i. ,0sp } } SYSTEMS County: <br /> s - ( POWTS) <br /> Safety and Buildings Division INSPECTION REPORT Address: cVQ Rd, <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION Sanitary Permit No: <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m1 I �� 26 (' <br /> Permit Holder's Name: 0 City 0 Village --.41 'own of: State Plan Transaction ID#: <br /> f vo-hovl 'Rik- 1..m co g. . 62.31V, <br /> Insp BM Elev: BM Description: Parcel Tax No: <br /> 1CO.ob l\kkik ivy 1(0" OA -fm t, los 13 <br /> TANK INFORMATIONELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic <br /> t1teSc 0) ( IG0D)(1O) Benchmark x.49 Io3.11 100.00 <br /> Dosing `vtc <br /> Aeration Ovtgt,+ c.xiStivue. 44o 8,(oo 95. 19 <br /> Holding St/Ht Inlet Ot.ve) 1000 9.00 q'f.1'9 <br /> TANK SETBACK INFORMATION St/Ht Outlet Otto Woo R. to 94.0 <br /> TANK TO P/L WELL BLDG VANTTOKEROAD Dt Inlet �L� 1000 9.12. 94 <br /> . <br /> 64 <br /> Septic ;50' 25' l0' >160' NA Dt Bottom AK) 1050 Q.41 qj.38 <br /> Dosing NA Installation <br /> Contour <br /> Aeration I NA Header/Man. t 9.5a' Rill.Z 1 <br /> Holding Dist. Pipe _ <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface 10.20 93.69 <br /> Manufacturer , Demand Final Grade <br /> Mod Number M <br /> TD Li riction Loss Sys ead 1,1eAFt , <br /> ain L Dia +Bisrr Well Top of lid <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS W 3 LQ't K22x23+tlo, #of Cells q Type of System Distribution Media Manufacturer: <br /> Ato—Conv o Aggregate <br /> SETBACK OHWM of Nay ��. ��. <br /> INFORMATION P/L Bldg Well Waters ❑ IGP Chamber <br /> o AG a EZFIow Model Number: <br /> CELL TO ?Sp' Ves' co' me ❑ Mound 0 Othera -17/ <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size i X Hole Observation Pipes <br /> Length ---Dia _ Dia Spac •_ ' . 4es 0 No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of tie:leecA.$) a MM <br /> Cell Center Cell Edges Topsoil CNo �fYes ❑No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) Elevations taken with Cor JGICASolA <br /> i4 604 s 5(45+e►v EktiocfrOvt Vertieo( * leffic Vc'.fs reluire Filter Manufacturer: ok <br /> St �a dulled/ 12" above Alai. Model: 5� <br /> G Ipat k r PO. oaroutt. Electrician: — <br /> (Field directive given to plumber that all electric/ . V -n necessary to ."co .leted by electrician per WI Adrnin Code.) 0 Yes IVo <br /> Plan revision required?D YeNo (O 2GJ 26 ,- . _ /4/$/5-93 <br /> Use other side for additional information Date POWT- .pe is Signature Certification Number <br />