010-941-21-1102-SAN-2021-286 i ,
RT"'� PRIVATE ONSITE WASTE TREATMENT County
��;`asP SYSTEMS Sawyer
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F''`���"� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 _ �'$�,
Pe�sonal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Viilage �Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
(a0,� � b� �•� o�� - 4�f1_ a( - (la�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,�Q �� Benchmark (�a,' �� ` �o o.o�
Dosing
Aeration Bldg. Sewer 6.w Y ' R y.a6'
Holding St/Ht Inlet 7.2 ' q�(.o'
TANK SETBACK INFORMATION St I Ht Outlet 7• 3 � q 3•q '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .� ' +(oa' ��� � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. 7.S ` g ,') �
Holding Dist.Pipe
PUMP/SIPHON INFORMATION �nfi�trative i
Surface �� `�'2 7�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO MATION
DIMENSIONS W � � �� �' ' #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav 1� Conv ❑ Aggregate � I
INFORMATION P�L Bidg Well Waters o GP � Chamber �
❑ EZFIow Model Number:
CELL TO ��` .�- ��,u ❑ Mound o Other QY�
DISTRIBUTION SYSTEM X Pressure Systems Only
9 9 P � )— — --- P ---. _ __I_----
Header/Manifold Distribution Pi e s � X Hole Size � X Hole Observation Pipes
Len th Dia Len th Dia S ac 1 Spacing ❑Yes ❑ No �
_ ---- -
SOIL COVER
Depth Over Depth Over � Depth of —� Seeded/Sodded � Mulched�
Cell Center � Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
Plan revision required?❑Yes❑ No I � l
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS AN� SKETCH
�/,�• SANITARY PERMIT NUMBER:___ �- � -o2g� _
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