010-941-23-3104-SAN-2021-276 -'�'`=''"""^%'; PRIVATE ONSITE WASTE TREATMENT county
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,�;; asp SYSTEMS Sawyer
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��'���'�^ ?� INSPECTiON REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION v2 ' - 02� �p
Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. I 5.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
G d-C-V(n5 Q��K�(wa�"1 (-�� wa�
Insp BM Elev: BM Description: Parcel Tax No:
(�.� ' `�o o� we-�� o�o _Q�f(-�3-310�'
TANK INFORMA ION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS • ELEV
Septic w� op� Benchmark ��'7` 0�.'7� 00,O'
Dosing '
Aeration Bldg. Sewer S''o'$ � °! .b 2�
Holding St/Ht Inlet 6, ( � �.6 �
TANK SETBACK INFORMATION St I Ht Outlet ` 6•3 '
TANK TO P/L WELL BLDG VENTTO ROAD Dt inlet
AIR INTAKE
Septic ��5� g'�r ' .}30� .f- a� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA HeaderlMan. (,,7,s- � q5�QS�
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM � 7�7-5� / ��(4��
TDH Lift Friction Loss Sys Head TDH Ft s s, � , S-� c�'Y•�
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � L �6� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��`j I ,
INFORMATION P I L Bldg Well �yaters o GP g� Chamber Model Number:
❑ EZFIow �
CELL TO .}�b �-� �}-(�,p � ❑ Mound � Other ,�,,�
— -- -- —� - _-- ----
- --- --.._
DISTRIBUTION SYSTEM X Pressure Systems Only
----- __ __ ____— ---
Header/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 l Mulched �
Cell Center Cell Edges 1 Topsoil ❑Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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_ ___ _ _
Plan revision required?�Yes❑ No d3 0( I�Z II -J � , / � �� � / �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA: _�=��___
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