024-741-30-5322-SAN-2021-315 -'�;�`-=°"-T"���:; PRIVATE ONSITE WASTE TREATMENT county
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'="��'���'" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� -- .3��
Petsonal 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 Descriptio : ���_t_ ����,t.��o.f �� ` 7 Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w�Q, (�opc� Benchmark 7 -p,�.sr
Dosing
Aeration Bldg. Sewer 3, I �
Holding St I Ht Inlet 3.?Y �
TANK SETBACK INFORMATION St/Ht Outlet 3,95' '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic ,� � `9 �}-�� ' NA Dt Bottom
Dosin NA Installation + �
9 Contour �6'a
Aeration NA Header I Man. �.�5'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION infiltrative
Surface
Manufacturer Demand Finai Grade
Model Number GPM , � 2���5�
TDH Lift Friction Loss Sys Head TDH Ft S � 7'•'>S�
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W ,3 � �Y 6Y` #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate ���
INFORMATION P I L Bldg Well Waters ^ o GP �Chamber Model Number:
❑ EZFIow
CELL TO �'� ,�- �{-�aa o Mound_ o Other QY,�
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifoid 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 � Depth of � Seeded/Sodded T Mulched
Cell Center �Cell Edges � Topsoil ❑Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision re uired?�Yes❑ No I� � �i��'--�. (7 �� � io
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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 NUMBER: _�_�=��__
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