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W4 �-6-0? 10;36 <br /> PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burrett County <br /> Visconsin ( POWTS) Property Address: <br /> Department of Commerce INSPECTION REPORT s <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION pp// <br /> Personal urIbcr ittion you provide my be used for secoo ft Law,s. 15.04(l)Lm) p b <br /> Permit Holders Nam 0 City LJ Village own of: State Plan Transaction IDN' <br /> _� ohn s Jt lJ1 SS <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> o3a-9o(a 01 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic S 4 o Benchmark <br /> Dosing /04 160,1.n <br /> Aeration <br /> Bldg.SeweraY 5. <br /> Holding St/Ht Inlet (p, eApy <br /> TANK SETBACK INFORMATION St/Ht Outlet !o Co g¢�8 <br /> TANK TO PIL WELL BLDG alR lrN acs ROAD Dt Inlet <br /> Septic �r _ x a p' NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> NA Header/Man. <br /> Holding Dist Pipe 64 <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface 76 93. 'f5 <br /> Manufacturer Demand Final Glade <br /> Model Number <br /> GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width /o Length 7Z No of cels 1 Type of System Manufacturer. <br /> SETBACK OHWMofNov t..a <br /> ntrPa�latw� LEACHING <br /> INFORMATION P/L Bldg Wei water _ CHAMBER Model Number. <br /> CELL TOf W1 x q0 ro be — L N'�yplTyl� <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length_ Dia_ Length�2 Dia 4„ Spac Spacing Wye ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Call Center Cell Edges To soil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) ch or ConF �w4+ow F9. <br /> �T aJ Z Ce1Jf % <br /> Uff <br /> Permit Posted? (0 N ° 4ed *'; �4s 6144 s>„itbs. <br /> Schedule 40 Vents and Observation Pipes? © N <br /> Cover Material: jyPAR p <br /> Effluent Filter Manufacturer T of ri)A.SK Model F"70 ?22 <br /> Components Not Inspected: <br /> Plan revision required?❑Yes❑No 7 D <br /> r 3 / <br /> Use other side for additional information Date POWrs pastor's Signatul Cert No <br />