020-639-12-2203-SAN-2021-291 ;y� �"T"E�� PRIVATE ONSITE WASTE TREATMENT county
���;�osp � ,, SYSTEMS SaWyer
`��,� s � ( POWTS)
\k\ �-P',
`x � "� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � „ �(I
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�1n�t���f�C¢ ('� h �j��`^'� �
Insp BM Elev: BM De cription: Parcel Tax No:
(o�,a� �esl�al� o� �4�e��,r �J.� c� - G39— c�.-�o�.
TANK INFORMATION ELEVATION DATA -
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV`
Septic Benchmark �,9's^'� o(.9S � o a•o�
Dosing
Aeration Bldg. Sewer ,7�� �j ,23�
t �
Holding G4 3 6D p St/Ht Inlet .2 S 0.7
TANK SETBACK INFORMATION St I Ht Outlet
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Hoiding oa` t -r�S �-��` L 2$ Dist.Pipe
PUMP/SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Fx
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav
❑ Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters o IGP ❑ Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO ❑ Mound o Other
— — - ----- ---- _ — -- -- ---
DISTRIBUTION SYSTEM X Pressure Systems Only
--— — --- -- -- —
___
Header/Manifold Distribution Pipe(s) l 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 � Topsoil ❑Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
���1� �I��-f2 �
� ��
Plan revision required?❑ Yes❑ No j d3 03 ae� I �7 / � ��(� r�
�___ w
Use other side for additionai information Date POWTS Inspector's Signature J Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: o'( ^���._
,
��
� c�� ��� �� .
���� � �q�
_�� � � 6�7?�u
t�
� �
�',�e�,Q ��
�-�o�
� �l'a
� M��
�
�� T�;I
��� , � H,�.,�
/ � L•� 3�oao
l , ��P��c.
D�'• �e
I �a
� y�. —�' �� lb a ���c .
w ° �� �
c� `
`'+��' � ����
V��
*-�--