014-842-14-3208-SAN-2021-328 �;�`�"'`"�^'-,� PRIVATE ONSITE WASTE TREATMENT county
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Safety and Buildings Division INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT)
GENERAL INFORMATION �t � 2 ��
Personal infonnation you provide may be used for secondary purposes[Prnacy 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 INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � . � �0o Benchmark 3.S f (p3� � Oo�� '
Dosing
Aeration Bldg. Sewer
Holding St I Ht Inlet
TANK SETBACK INFORMATION St I Ht outlet �.�S ` q+{,2,5
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic .��p` � � .},1s' .��5 ' NA DtBottom
Dosing NA Installation
Contour
Aeration NA Header/Man. /�,'�$� Q�,'���
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfi�trative �1
Surface �l�7 f l�•� (
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 W 3 � O` (o #of Cells 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 , fi �p' � �� ❑ Mound o Other —
---- -- - --. --__-- -
DISTRIBUTION SYST M X Pressure Systems Only
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Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes i
Length Dia Length Dia Spac _� _ Spacing ❑Yes ❑No I
SOIL COVER
�pth Over �Depth Over 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 p � ��
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL C�MMENTS ANO SKETCH
SANITARY PERMIT NUMBER: _ �( � 32 g__
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