008-937-21-2306-SAN-2021-308 /�-�``� PRIVATE ONSITE WASTE TREATMENT County
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°`s`-'�-�"•' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a 1 ' 3 ��
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#:
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Insp BM Elev: BM Description: Parcel Tax No:
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TANK INF RMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark S 3' bs, �3� (oo.D �
Dosing
Aeration Bldg. Sewer 6,`� � �6 '
Holding w�,¢�,�— 3a� St/Ht Inlet '�,qq �
TANK SETBACK INFORMATION St I Ht Outlet ,3,z� c� ��
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding ��� -}-��� �7� ��7 L2�— Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative
Surface
Manufacturer 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 L #of Ceils Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO ❑ Mound o Other
— _— --- --— --- --- ---- —
DISTRIBUTION SYSTEM X Pressure Systems Only
— -- --- —
Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length _ Dia_ ___ Spac � Spacing ❑ Yes ❑ No �
SOIL COVER
Depth Over Depth 9ver Depth of — Seeded/Sodded Mulched �
Cell Center l Cell Ed es To soil _ � ❑Yes ❑ No ��Yes ❑ Nc
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑ Yes❑ No D p� �3 ^
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AO�ITIONAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NlJMBEA: �� �-3g$
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