032-539-02-1101-SAN-2020-313 � �"""`%' PRIVATE ONSITE WASTE TREATMENT county
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INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� � � ��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village �,Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �� �Os;a4� (pd•c��
Dosing
Aeration Bltlg. Sewer �1 � 13.0' 9 2 2R
Holding s�� �o„�� �2� -7 �/Htlnlet b�•.2 � 9'�.oQ�
TANK SETBACK INFORMATION /Ht Outlet �33 ' ,96�
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom 1�.`{ ' q �,gq�
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding 3�r� t(oa' �'�oo` �too .. �-�' Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM f4 � �6� q�'� 6`Y �
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound � Other
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DISTRIBUTION SYSTEM x Pressure Systems Only
--___ - --
Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑No �
._- _ _- -_- __ __. .. -__L- - -_._ _'___ ____""_-_
SOIL COVER _
Depth Over Depth Over �Depth of _ i Seeded/Sodded � Mulched �
Cell Center Cell Etlges Topsoil � ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑ Yes ❑ No �I �? j z3Jl �i - L%�-`_/�_ ___ J 6`� �I � �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SqNITAPv PEqMIT NLIMBER�. ___ .2�_'.3��_ __
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