002-109-49-0102-SAN-2021-278 '"�"'"'`"'`� PRIVATE ONSITE WASTE TREATMENT county
;y���a SYSTEMS Sawyer
�,� Ps ( POWTS)
�. � �— ��;:
\�`"' 'y� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �. l _ �'7 g
Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. l 5.04(1)(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:
i 1
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TANK IN 0 MATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,"�� -7� Benchmark (po,a'
Dosing
Aeration Bldg. Sewer cr3,Q�
Holding St I Ht Inlet 9 3�g
TANK SETBACK INFORMATION St I Ht Outlet q S'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �ou� � h-g NA Dt Bottom
Dosing NA installation
Contour
Aeration NA Header/Man. �3,o'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface ��•a�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weil
DISPERSAL CELL INFORMATION
DIMENSIONS W � L #of Ceils ( Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P I L Bldg Well �/yaters � �GP � Chamber Model Number:
❑ AG ❑ EZFIow
(U � ❑ Mound o Other
CELL TO �1-toa� _ _�_�----
-- - -- -____ - -__ ----
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 __ �I
SOIL COVER
— - ----- --- —
Depth Over Depth Over � Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges Topsoil _ __ ❑Yes ❑ No 0 Yes � No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AO�ITIONAL C�MMENTS ANO SKETCH
SANITARY PERMIT N�JMBER 2 ( - �7 S
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