026-939-21-5202-SAN-2021-300 ���°�'"'`"��%;, PRIVATE ONSITE WASTE TREATMENT co��ty
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( POWTS) SaWyer
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�='''�=����='" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� �� �O
Personal infonnatio�you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(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:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic l �- $�(O Benchmark ?,`j �O7 9 ` op,o '
Dosing - coh,�a-o �a
Aeration Bldg. Sewer
4.(s lo . '
Holding St/Ht Inlet � 6 v`
TANK SETBACK INFORMATION St I Ht Outlet �� r ,� g'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic (o` +�.5` 6� fi NA Dt Bottom �.$ � , 9 �� �
Instailation
Dosing �� �� � ,, NA Contour -
Aeration NA Header/Man. 3,a � i� t
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION �nflltrative � ,
Surface �� aY.o
Manufacturer L, Demand Final Grade
Model Number � GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L � � Dia � '` Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N 6 ,�� L Gr3, o ` #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv � Aggregate
INFORMATION P I L Bldg Well Waters o IGP ❑ Chamber
❑ AG ❑ EZFIow Model Number:
CELLTO �'"(p' -f-(�`j ' N ,� Mound � Other
-- - — —
----- - - -- --
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold �� Distribution Pipe(s) .��� ' , ' X Hole Size I X Hole �o� Observation Pipes
Length� Dia l.S _ Length�6 Dia_ � � Spac 3 `�� L_ p,�� Spacing ' �Yes ❑ No
SOIL COVER -
-- ---- --- --- ----- --- - --
Depth Over �� Depth Over ,, Depth of r, Seeded/Sodded Mulched
Cell Center ��- Cell Edges �,- Topsoil ��— �Yes ❑ No � �Yes ❑ No �
COMMENTS: (Include code discrepancies, persons present,etc.)
���I�cs11 �o �S��2 (
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Plan revision required?❑ Yes O No i ,
. ��31�`� .2 i ------- — � � (
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBER:___��_�3 OO
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