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NOIsciansin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 3 <br /> Personal information you provide my be used for secondary ses I Privacy Law,s.15.04 1 m <br /> Permit'�� I er's Name: t� State Plan Transaction IDIS: <br /> a J eer Town of: v a ofl <br /> CST BM Elev: Insp BM Elev: BM Des c' to Parcel Tax No: <br /> S 5 7� <br /> TANK INFORMATION ELEVATION DASA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Ort,LI�S c' Benchmark Jf, <br /> Dosing <br /> Aeration Bldg.Sewer S <br /> Holding St/Ht Inlet 05 <br /> TANK SETBACK INFORMATION St/Ht Outlet , <br /> TANK TO P/L WELL BLDG R"�oE ROAD Dt Inlet <br /> Septic >2-s 5 y NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist.Pipe pjZZ <br /> PUMP I SIPHON INFORMATION System <br /> Elevation 8 3 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM 7•` �/. <br /> TDH Lift Friction LossSystem Head MH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS WidthLength�a NoolCells Type of System Manufacturer. <br /> SETBACK tOHWMof Nav 1Y1—gra LE ACHINGINFORMATION P/L Bldg Well Ce Model Number: <br /> TOCELL _ > �Z5 - <br /> DISTRIBUTION SYSTEM x Pressure systems only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole rvation Pipes <br /> Length — Dia:i�_r;Length�� Dia �` Spec I SpacingY s ON o <br /> SOIL COVER <br /> Depth Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center S bJ Cell Edges �'� To 'I 0 Yes 0 No 0 Yes 0 No <br /> COMMENTS: (Include code disc repan ' ,persons�present,etc.) <br /> Components Not Inspected <br /> 1- Permit Posted Cover Material r/ /ler C� -9k -FIW4'�o f Co&Il <br /> �E <br /> o Warning labels on manhole covers w/locks rook..' 776 we#' arliz*iff <br /> -it Schedule 40 Vent Material ^' I <br /> g Effluent Filter installed Model OD MFR. <br /> Plan revision required(Yes 13 No <br /> Use other side for additional information Date POWTIS Inspector's Signature Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R(3101) <br />