014-842-16-4416-SAN-2021-288 =���"'"T"f�'- PRIVATE ONSITE WASTE TREATMENT county
iy;'��a$ ,�; SYSTEMS Sawyer
�:�,� PS '� ( POWTS)
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"''=��'��% INSPECTION REPORT Sanitary Permit No:
Safery and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �,I r��g
Personal infonnation you provide may be used for secondary purposes[Pnvacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�Qh�.S �G�.�-�1Cz+ ��(S o v� �-e.ln�D a`� '�
Insp BM Elev: BM Description: Parcel Tax No:
CoO1 1- (�- /
�c conc. c�vwll� ih^�ti o'� (ewa.- e�n'� ��S- �I�{ - �Y2 -lb - `ly l�o
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic u,���sZr ��5� Benchmark ��,�p,o '
Dosing
Aeration Bldg. Sewer q ,�S'
Holding St I Ht Inlet 4 ,qY�
TANK SETBACK INFORMATION St/Ht Outlet 97 bS'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .��,5' .�-�S' ��{� �}-��( ` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �j?,o'
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM S � �-�•d
TDH Lift Friction Loss Sys Head TDH Ft .$y) 2 �j0,s''
Forcemain L Dia Dist.To Well 3 ,p`
DISPERSAL CELL INFORMATION
DIMENSIONS W 3 L(o�' � / #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �
INFORMATION P/L Bldg Weli Waters °� G p� Chamber Model Number:
❑ EZFIow
CELL TO '��o` t,2 'a /v o Mound � Other Q,,�,�
-- __ — - --- ____ ---— --—
DISTRIBUTION SYSTEM X Pressure Systems Oniy
Header/Manifold Distribution Pipe(sj I X Hole Si2e X Hole Observation Pipes
Length Dia _I Length Dia _ _ Spac j __ ' Spacing ❑Yes _0 No
SOIL COVER
Depth Over Depth Over ! Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges � Topsoil __ _ ❑Xes ❑ No ❑Yes 0 No 1
COMMENTS: (Include code discrepancies, persons present,etc.)
�--�.S�a�� �l ���02 �
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Plan revision required?�Yes ❑ No 3 � ^ /„ lj q� �
O 0.2 ��, '� ���— "�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITI�NAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBEA� __��-02�_
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