010-841-27-5302-SAN-2021-297 !r�
`'"""`�'; PRIVATE ONSITE WASTE TREATMENT county
'� �s SYSTEMS Sawyer
���� �s ( POWTS)
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�'>'�"��'�'" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �,� — a Q(�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
c�v�_,l�n,►G d'`q�+► D�Gc�( �4�waS'd\ �
Insp BM Elev: BM Description: Parcel Tax No:
i�.� �va� �--�`�b��. ��, � 3.� �k � o�o _ �Y r -�� -- ���
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,, ;e �,�,� �� q�j Benchmark �,tj` (OO.p` l00.0�
Dosing
Aeration Bldg. Sewer •�.( � �0.(,'
Holding St/Htlnlet IO,O � RO,pt
TANK SETBACK INFORMATION St/Ht Outlet (p,�$' $�,? �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .�� t � �,Z� ,�.�� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. � (p.$ � �, 2'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative i . �
Surface I l•6S 8$3.�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INF RMAT N
DIMENSIONS W � � $S #of Ceils 3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
P I L Bldg Well o IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO ��S �'�-o .�-� _ ❑ Mound o 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 Mulched
Cell Center Cell Edges I Topsoil __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No I �j 3 �p3 ' �� I _ ��. � --- � l9�� ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH �� 1 f I,� _
SANITAflY PERMIT NUMAER. 02 iZ�� ���� `�V"���
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