010-841-14-5106-SAN-2021-341 ""' PRIVATE ONSITE WASTE TREATMENT co�nry
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''='"�^'=' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION '„Z, 1 � 3�(�
Pe�sonal infonnation you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village [a Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: 1_p � �,,,e ; �a /, Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �„r�e� - ���� Benchmark j � — -
Dosing �- c.o��o� $O� � �� � q,�s� 1�.0�
Aeration Bldg. Sewer � -
Holding St/Ht Inlet �r,��
TANK SETBACK INFORMATION St I Ht Outlet ��, y -
TANK TO P/L WELL BLDG vENr To ROAD Dt inlet
AIR INTAKE
Septic -1-�5� �-(b� �-�' +�p' NA Dt Bottom (g.$-
Dosing N .� « •� NA Installation
Contour
Aeration NA Header/Man. g,�. '
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiitrative
Surface
Manufacturer a�, Demand Final Grade
Model Number �^� ( � GPM Sys. ( ����
TDH��� Lift Friction Loss Sys Head TDH Ft Sy,S. 2 9.S `
Forcemain L 2p' Dia �.`� Dist.To Well ,s�, 3 (o.3S �
DISPERSAL CELL INFORMATION ; �. �g.o
DIMENSIONS W 3' � 60� bo' ,(,S � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ aggregate
INFORMATION P/L Bldg Well Waters �° A P cr Chamber Model Number:
❑ (`, {� EZFIow
CELL TO � � ` �(� � -{-�j' ❑ Mound o Other
--- - - — - -- - —
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 De tp h of Seeded/Sodded Mulched
Cell Center �ell Edges Topsoil __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?0 Yes❑ No �' p 3 io$ a.� � -. / J �jc� ���
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3l01)
A�OITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER _i__��_.�-��I ___
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