014-942-34-4401-SAN-2021-324 �;�''"T'� PRIVATE ONSITE WASTE TREATMENT co�nty
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� —� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 21 _ 3� l�
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,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: Parcei Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION �S HI FS ELEV
Septic „�,ie�- l �� Benchmark (pp,a�
Dosing '-7 Sb
Aeration Bidg. Sewer � 3.�r
Holding St/Ht Inlet ��, °Y'
TANK SETBACK INFORMATION St I Ht Outlet 7$'7� r
TANK TO P/L WELL BLDG VENT TO ROAD Dt inlet ^� .p
AIR INTAKE L�p 7 I
1 NA Dt Bottom 7 �
Septic kto� kSv� �S� )• `�
Dosing .} � � � � NA Installation ,
-�b `� h"S �l-'S" Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �,k � � �QgY,
Surface �� '�
Manufacturer �q •�� Demand Final Grade
Model Number �� � GPM
TDH� Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATIO � ce(
DIMENSIONS W � ' d p' � #of Cells 3 � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv o Aggregate �t
INFORMATION P I L Bldg Well Waters o GP �i Chamber Model Number:
❑ EZFIow
CELLTO �- (oo dp` �-�do ❑ Mound o Other Q,�,r
DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/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 1 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 � �3 ! 07 �� � �� � � �� �� ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER ____�_I--3 2�__
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