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fo <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett Court <br /> Visconsin ( POWTS) P Ad&M: at03 <br /> Department of Commerce INSPECTION REPORT A <br /> sabty ww ewwlims oi+ (ATTACH TO PERMIT) Sanitary Pedirnit No: <br /> GENERAL INFORMATION BM Desc �� I� <br /> Pasonal iofornistion ou ma hsed x <br /> provide ufor son PrivacyLaw,s 15.04(1 m <br /> Perm�-lokWs Name: BM City village d: State Plan TransacP7tion IDA: <br /> CST BM Elev: Ina Eley. Description: Parcel Tax No: <br /> IGYI.00 c Tntc Ot,�/ee{ dgk)a 6,er o) <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> �c 500 s1bA Benchmark <br /> Dosing &jWTtj'Mea 4. A//5 /Orf,� /00. o0 <br /> Aeration Bldg.Sewer <br /> Holding St I Ht Inlet ra(SI 99 <br /> TANK SETBACK INFORMATION St I Ht outlet �z 93 <br /> • n <br /> TANK TO PIL WELL BLDG �TTOO ROAD Dt Inlet <br /> Septic x40 X NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header I Man. <br /> Holding Dist Pipe <br /> Inrative <br /> PUMP 1 SIPHON INFORMATION Surfrhacedce <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 /> DWENSIONS Width It Length 23 Type of System Manufacturer: <br /> SETWK LEACHING <br /> INFORMATION P I L Bldg we+ wwalof CHAMBER Model Number.N/A <br /> CELL TO y 5' 3O' >S0' A14 isn4 1.6J /VA <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I ManifoldDishibution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length= Dia — Length_ Dia= Spec Spacing ❑Yes ❑No <br /> SOIL COVER <br /> Deplh Over Depth Over Depth of Seeded I Sodded Mulched <br /> CeN Center Cell Edges Topsail ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? (fK) N <br /> Schedule 40 Vents and Observation Pipes?t N <br /> Cover Material: s/AA <br /> Effluent Filter Manufacturer BEST' Model C� /0-S <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 2 �d8 b ( 3 I <br /> Use other side for additional information Date POWTS spector's Signatu Cert No <br />