014-942-35-3315-SAN-2021-330 -'�•t""'"`^> PRIVATE ONSITE WASTE TREATMENT county
���;'��a �` SYSTEMS Sawyer
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— INSPECTION REPORT sanita Permit No:
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Safery and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � ` - �3a
Personal infonnatio�you provide may be used for secondary pucposes[Privacy Law,s. 15.04(1)(in)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: By� �� a Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark p,l y � (o�.�Y � f�.�'
Dosing tnn � �/, 18� 9 S96'
Aeration Bldg. Sewer :7�' �3.36'
Holding w�'¢r�� b gpp St I Ht Inlet .o� � �3•�3'
TANK SETBACK INFORMATION St I Ht Outlet 7, Y� ' � ,6�r'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom (0.6$ � �j, 6'
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding ' � N c/ f� ��S' Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative
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 W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters a G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) �X Hole Size X Hole Observation Pipes
Length Dia l Length Dia _ Spac _� _ Spacing ❑Yes ❑ No
SOIL COVER
Depth Over Depth Over � Depth of—� Seeded/Sodded I 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 ; og aa _ �7�� J, �j`C ���,
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADDITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA _____�-3�___
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