032-338-22-5708-SAN-2021-206 ���>'�'``, � PRIVATE ONSITE WAS�E TREATMENT county
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�s—'�y'=' INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � ` � �O�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.Q4(l)(m)J
Permit Holder's Name: ❑City ❑ Village [$Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
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lob.� o ,we �s�- ,, ` o3a-338-�2-��b8
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic VI�Q, — � Benchmark po•o�
Dosing r-cD,,,��p 7�j
Aeration Bldg. Sewer r—
Holding St/Ht tnlet 4s y3'
TANK SETBACK INFORMATION St I Ht Outlet S-� �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic h�,� ��� ,�pa' .hpo� NA Dt Bottom qa,�'
Dosing u �, r , NA Installation ��
Contour `��'�
Aeration NA Header/Man. �a;�.(
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �
Surface l01,33
Manufacturer �_ �— Demantl Final Grade
Modei Number �j''$ GPM
TDH � Lift Friction Loss Sys Head TDH Ft
Forcemain � r�5� Dia �` Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer:
❑ Conv ❑ Aggregate ��'p�
SETBACK OHWM of Nav .�
INFORMATION P 1 L Bldg Well Waters � GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO �
Mound `� Other
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
SOIL COVER — —
_ —_ _ — -
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center � Cell Edges I Topsoil __�— ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inclutle code discrepancies, persons present,etc.)
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Plan revision required?�Yes O No D a$ a 3 � � � (��� ,� �
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Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT NLJMBEA; �I��O�o ����� ��N
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