010-841-36-5707-SAN-2021-299 -�t'`'"'"'���; PRIVATE ONSITE WASTE TREATMENT county
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"' ���� INSPECTION REPORT sanitary Permit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 _ �Z��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,;e,�— ��� Benchmark �,�'S� (c��,s ' ('oe.o'
Dosing
Aeration Bidg. Sewer y�(S'' �($,(
Holding St/Ht Inlet 5' ( ` `f'),YS-�
TANK SETBACK INFORMATION St I Ht Outlet S.3 � 9 7,� '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .�1.s' fi� � �� fi � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ,�.S � `17.oS�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative i �
Surface 6•s `�6.oS
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMAT N
DIMENSIONS W ,3 � � 5� ' �' #of Cells Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate
SETBACK P/L Bldg Well OHWM of Nav � �GP p� Chamber � � '
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO �� .y- �j- a-�' ❑ Mound o Other �'1�,�
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia_ _ Spac_� Spacing ❑Yes ❑ No
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SOIL COVER
Depth Over Depth Over I Depth of Seeded/Sodded Mulched
Cell Center Cell Edges � Topsoil ❑Yes ❑ No ❑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)
A�DITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NIJMBEA___�(_r-�Q� ___
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