008-937-24-1201-SAN-2021-354 �i�� `�` ,. PRIVATE ONSITE WASTE TREATMENT �ounty
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��`=s'�"-^`' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � l � 3�
Personal infonnation you provide may be used foc secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village I�.Town of: State Plan Transaction ID#:
Si� 1-�a e� L (.� C- ,a�� �P^��o�21 o�-f7 9- �
Insp BM Elev: BM Description: Parcel Tax No:
(ao.�' ?�� oc�g- -`�'r 3 I- 2Y- 1�� ►
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ��-- �ag�J Benchmark (OG.o �
Dosing ��,,,,1�0 $a a
Aeration Bldg. Sewer $7,�,5'r
Holding St/Ht Inlet �(,,�"�
TANK SETBACK INFORMATION St/Ht outlet �,75'�
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic �oo` !V A -}�,2.s' d--,�,s� NA Dt Bottom $3, � �
Dosing �� �� ^ •� NA Installation �
Contour l03,0
Aeration NA Header I Man.
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �
Surface lo��o
Manufacturer Demand Final Grade
Model Number � GPM �e���- �o�d �
TDH�� Lift Friction Loss Sys Head TDH Ft �(° � l 6 s"�
A o ,o
Forcemain L �(g�� Dia �'� Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W • L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate �i`��
INFORMATION P I L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO � Mound D�C Other
-- - — --— - ---
DISTRIBUTION SYSTEM �1_�" x Pressure Systems Oniy
-- - -- - - - - -
Header I Manifpld �� Distribution Pipe(s) X Hole ig , X Hole ���' Observation Pipes
Length � Dia � Length D' pac 3��b � Spacing Yes ❑ No
- -----
- --- --------.
SOIL COVER
Depth Over �� Depth Over �, Depth of /� y Seeded 1 Sodded Mulchetl
Cell Center �01- Cell Etlges �� Topsoil _ C� _____�'Yes ❑ No [�Yes ❑ N�
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COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes ❑ No �z l Y �3 �-(�_ - --- � / `,� � '�
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Use other side for atlditional information Date POWTS Inspector s Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO�KETCH
SANITAAY PEAMIT NUMBEA; 't.�-� SY
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