032-540-36-5513-SAN-2021-316 -'"�=""T"'�'�;, PRIVATE ONSITE WASTE TREATMENT county
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' ���'�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 1� 3(�
Personal infonnatio�you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)]
Pertnit Hoider's Name: ❑City ❑ Village [�,Town of: State Plan Transaction ID#:
oWa� �}-lX'wCe ��1\ �(�,n� �
Insp BM Elev: BM Description: Parcel Tax No:
lt�•�` � � � v3�-5'�Co-3�-S3't3
TANK INF RMATI N ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,� dtja Benchmark � $� p�.$' �pp,p�
Dosing
Aeration Bldg. Sewer ,� � c� Z�
Holding St I Ht inlet ? p ` �j .o '
TANK SETBACK INFORMATION St/Ht Outlet ,os' ` q 7S-r
TANK TO P/L WELL BLDG VENTTO ROAD Dt inlet
AIR INTAKE
Septic .}�� �,J NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. f
`�'..g � ,�.��
Holding Dist.Pipe
PUMP I SIPHON INFORMATION Infiltrative � �r
Surface ���$ �� •
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO MATION
DIMENSIONS �N � L a0` '$a #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �� �
INFORMATION P!L Bidg Well �yaters � IGP �Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO �}-� N � �� o Mound � Other /1 �
- - — - --- �!y —
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 � Topsoil___ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
''���"'�Snt/�Q� ��(1 �-� �- �
Plan revision required?0 Yes❑ No � -
!03 '�o� a-� �-- �-�,��� � 6� S� C�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: ��"��� __
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