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W15 , <br /> Visconsin <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Bumett County <br /> ( POWTS) Pmpeny Address <br /> Department of Commerce INSPECTION REPORT JA 50 W,*U <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION c/"a3_Q� 3d <br /> Personal infommtion you pmide my be used for secon s I Privacy Law,s. 15.04 1 m)I L14L�-1q:7+ <br /> Permit Holder's Name: CityLJ Village own of: State Plan Transacti n IDM: <br /> CST BM Elev: Insp BM Elev: BM Description: 1 Parcel Tax No: <br /> 100. O sAMP RIL 1rJ PI/M ,?4" <br /> TANK INFORMATION ELEVATION DATA ' <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic W � 6C> Gals rnJ Benchmark 4"14 92 100. 00 <br /> Dosing <br /> Aeration Bldg.Sewer ?7A <br /> Holding St/Ht Inlet 25 <br /> TANK SETBACK INFORMATION St/Ht outlet at 1o' 9 0 <br /> TANK TO I P/L I WELL BLDG VENT To ROAD Dt Inlet <br /> NR INTAKE <br /> Septic >-Iod >100 9, — NA DtBottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. g' 2' 9.575 <br /> Holding Dist Pipe ,s' 95.50 <br /> PUMP/SIPHON INFORMATION Surface Infiltrative <br /> I& 5� 4.50 <br /> Manufacturer Demand Final Grade 15, <br /> Model Number GPM <br /> TDH Uft Friction Loss System Head TDH Ft 3WM6 Pr C" 5'2* 19 7 <br /> Forcemain Length Dia Dist.To Well s fev �/ /9'�' 75 <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width 3' Length No No of Cells Z rofSystem Manufacturer.SETBACK OHWMofNov LEACHING B10D1W,)5EQ <br /> INFORMATION P/L Bldg wen WatersCHAMBERModel Number: <br /> CELL TO 7 /00' >/c — 51AM0A2O II" <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length—T— Dia'�° Length_ Dia_ Spec Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Ed To <br /> soil ❑Yes ❑No C3 Yes' ❑No <br /> COMMENTS: (include code discrepandes,persons present,etc.) 641STu.16 6c�- BE PIT Was FA 14nlss, /u 4-v6 of 5hr'WT1' 1 GGcu. <br /> Permit Posted? (V N <br /> Schedule 40 Vents and Observation Pipes N <br /> Cover Material: IVIA <br /> Effluent Filter Manufacturer XTaBEL Model A-/oo-Iz <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 7 1 O f 3 / <br /> Use other side for additional information Date POWT speclor's Sign atu Cert No <br />