012-279-00-0400-SAN-2021-364 '��``"T';t�,�, . PRIVATE ONSITE WASTE TREATMENT co�nty
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'"'"'j�,�' INSPECTION REPORT sanitary Permit tvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ' �( �36 y
Personal infonnation you provide may be used for secondary purposes[Privacy 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 Descri ion: Parcel Tax No:
(cx�,a` Na; � n�oboh Y8" � l�'s;�e.. 30" 4 � oca — at�� -60-c5`loa
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,�,���- � pop Benchmark �pp,d�
Dosing
Aeration Bldg. Sewer o .��-�
Holding St/Ht Inlet �cr��'
TANK SETBACK INFORMATION St I Ht Outlet o .q �
TANK TO P/L WELL BLDG VENTTO ROAD Dt inlet '
AIR INTAKE
Septic �-�a� ,f-�uj �--5' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �j^���
Holding Dist.Pipe
PUMP I SIPHON INFORMATION Infiltrative �� ��83�
Surface
Manufacturer Demand Final Grade
Model Number GPM Stils� `-t5:oy
TDH Lift Friction Loss Sys Head TDH Ft S l 3 9�(,07�
Forcemain L Dia Dist. To Well S Y 3•3� '
DISPERSAL CELL INFORMATION
DIMENSIONS W 3 � 3,2� 2� �. � #of Cells Type of System Distnbution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ ,Aggregate �'�
INFORMATION P I L Bldg Well Waters o GP � Chamber Model Number: �
❑ EZFIow
CELL TO ��j ���,' �(vv� �-(Oa ❑ Mound o Other _ �Y�
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia �ength Dia_ _ _ Spac __1 _ _ __ Spacing ❑Yes ❑ No
SOIL COVER
Depth Over Depth Over Depth of Seeded I 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 � �� � � G�J�� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIDNAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA.__��_�_____
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