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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County"rU63 <br /> Vhwmsin ( POWTS) Pro rty Address: <br /> Department of Commerce INSPECTION REPORT �- <br /> Safety and Buildings Division (ATTACH TO <br /> _ Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide m be used for second ses PrivacyLaw,s. 15.04 7 m --' <br /> Pe otder'a Ns1ne: � State Plan Transaction ID#: <br /> U,G�C7. Town of: 2 Cm`- l <br /> CST�PIM Elev: Insp BM Elew BM Description: Parcel Tax No: <br /> a0. 00 SAM 6-� MAIL Pj RQ PSE 962) <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic /,ZUO - 750 4.(- Benchmark /0 15 100•oo <br /> Dosing -C 2nD02 Bids ^%,w 5.3b 5'e <br /> Aeration Bldg.Sewer .5„la 99.05 <br /> Holding St I Ht Inlet 15$0 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO I P/L WELL BLDG AIRIVENNTATAKE ROAD Dt Inlet <br /> AIR I <br /> Septic Ar — NA Dt Bottom <br /> Dosing _ NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe r S,92. 98.3 <br /> PUMP/SIPHON INFORMATION System <br /> Elevation i , 75 97,5D <br /> Manufacturer <br /> Demand Final Grade "'o� <br /> PMWr 5-a Kft Fill <br /> Model Number GPM -Aysfeml 6c 2 4- 75 95,92 9833 97.50 <br /> Lift Fr.Loss Head TDH -VS144 Q, 3 7,25 9(03(a 97- 81 97• oo <br /> Forcemain Length Dia Dist/Well SysTGrr Et 4 775 Co.9Z 97. 33 910. 50 <br /> DISPERSAL CELL INFORMATION sysr6m C. s 3.,Z507,0Z 910. 83 910, 00 <br /> DIMENSIONS Width Length(q0 No of Cells 15 Type of System Manufacturer. <br /> SETBACK p/L Bldg Well OHWM of Nev LEACHING <br /> INFORMATION g CHAMBER Waters Model Number: <br /> CELL TO >ivo '5 >(Op > 00 C.I.6- <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length — Dia — Length & Dia Spec <br /> ❑Yes, ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center I Cell Edges Topsdl ❑Yes ❑No 1 ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> SKAW ,200o 6G+taLV,) Sf'PfrL 11wc Is NOT Components Not Inspected <br /> Corj(4 Go As % -rwo Co^04tTx&49 -PwY-.$* Aw'1`100 wAu. Is OPW. Su Ce-/( /!vt cp.,Olt£e_ @ <br /> wl Permit Posted Cover Material 7WAC rrospe cion. <br /> er Warning labels on manhole covers w/locks <br /> id Schedule 40 Vent Material <br /> ca' Effluent Filter installed Model -I 0 FR. EL <br /> Plan revision required?❑Yes❑No -4 v) <br /> Use other side for additional information Date PO Inspector's Sign re Cert No <br /> Bureau of Field Operations,PO Box 7302,Madison,WI 53701-7302 SBD-6710 R 3101 ) <br />