024-741-14-4102-SAN-2021-353 '�t='"'`"'��;; PRIVATE ONSITE WASTE TREATMENT county
�i�'��aSp `,;t., SYSTEMS Sawyer
`����� s '�r ( POWTS)
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�-- INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �t — ��3
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Viliage Town of: State Plan Transaction ID#:
Q2�-�f' �aiHG �o�n� La�
Insp BM Elev: BM Description: Parcel Tax No: ��y(� 2
lO�.p� �d��.,, s��� t�'I�v..) c.a..Ar a�� �j o2��Y i-rY- Y/o�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic e S ` Benchmark �,o � �O�,�� �po,p �
Dosing .
Aeration Bldg. Sewer '
Holding St I Ht Inlet
TANK SETBACK INFORMATION St I Ht Outlet ,,tg-' �'i$.75�
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA HeaderlMan. sp ' Q�,o�
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Surf cte e ��a � `t6•o f
Manufacturer Demand Final Grade ,a � 9`T.o'
Model Number GPM e ` ,S 7�a � �f s.p�
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N 3 ' L �` (�p' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate � � �
INFORMATION P/L Bldg Well Waters � IGP � Chamber
❑ AG ❑ EZFIow Model Number:
CELLTO ^��o� '��. ❑ Mound o Other �,�,�
DISTRIBUTION SYSTEM X Pressure Systems Only
— --- — ---__-, ------
Header/Manifold Distribution Pipe(s) I X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No �
SOIL COVER �J
Depth Over �Depth Over i Depth of Seeded/Sodded Mulched
Cell Center Cell Edges I Topsoil � ❑Yes ❑ No ❑Yes ❑ No 1
COMMENTS: (Include code discrepancies,persons present,etc.)
��,s��� I1 �3 �� 1
� -S.� .S_ ����e.�.�,-�
— ----__-- -
Plan revision required?❑ Yes❑ No �Q 3 O �
; 9 �`2 �_-��_ —__J � � 5���
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 NUMBEA:__��
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