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1, /�/� PRIVATE ONSITE ,n1`'ASTE TREATMENT SYSTEMS Burnett County <br /> sconsin !. ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT <br /> Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No: <br /> GENERAL INFORMATION 5 3 a <br /> Personal information you provide my be used for secondary ses[Privacy Law,s. 15.04(1 m) <br /> Permil Holders Name: cityLJ village Town of: State Plan Transaction IDB: <br /> �S W) z9U, <br /> CST BM Elev: [nap BM ev: BM Description: Parcel Tax No: <br /> X00. 00 5&nz ail in R«f QWL)o• 6)3-33a6-0)- <br /> TANK <br /> )3-33a6o -TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic 65L 000 6610"s Benchmark At. 7o IoY.7o /CO. 00 <br /> Dosing <br /> Aeration Bldg.Sewer 99 yg ¢ <br /> Holding St/Ht Inlet —91.3s <br /> TANK SETBACK INFORMATION St/Ht Outlet 01 . 00 <br /> TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic >)C67r�' 10' — NA DtBottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. o <br /> Holding Dist Pipe 7.Z3 97-rf <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface Sop 96• 7V <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 I Width .3 Length C)CINo of Calls z Type of System Manufacturer: <br /> SETBACK OHWMofNay 6onueui"al LEACHING z FLOW <br /> INFORMATION P/L Bldg well Waters CHAMBER Model Number: <br /> In• �M"d <br /> CELL TO >/00' .Z O' >86' o G—Z /20 -J 9/6—w-- <br /> DISTRIBUTION <br /> 6—wDISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length_ Dia Length_ Dia_ Spec Spacing ❑Yes ❑ No <br /> SOIL COVER <br /> Depth Over Depth Over Depth ol Seeded I Sodded Mulched 1 <br /> Cell Center Cell Ed es Tpsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> Permit Posted? Y N <br /> Schedule 40 Ven s and Observation Pipes?oY N <br /> Cover Material: oV/A <br /> Effluent Filter Manufacturer c Model 52K <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 1 71 O I 3 <br /> 11 1 <br /> Use other side for additional information Date PO nspector's Sign Cert No <br />