002-940-04-3113-SAN-2021-375 '�="''�T"�`%: PRIVATE ONSITE WASTE TREATMENT co�nty
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ry f�—�/ INSPECTION REPORT Sanitary Permit No:
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Safety and Buildings Division (ATTACH TO PERMIT)
GENERALINFORMATION �1 � 37�
Personal infonnation you provide may be used Yor secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Pian Transaction ID#:
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Insp BM Elev: BM Description: Parcei Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic wj � Benchmark �p�.��
Dosing
Aeration Bldg. Sewer q y3�
Holding St I Ht Inlet �� 3 r
TANK SETBACK INFORMATION St I Ht Outlet �, `
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic �� � g� }.g` NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. 9 ,Y6'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative q��,�i
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 �N � L (,g' 6$` #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav t� Conv ❑ Aggregate ��, I
P I L Bldg Well ❑ IGP � Chamber ��
INFORMATION Waters Model Number:
❑ AG ❑ EZFIow
CELL TO +;�' ,`-.�_ ❑ Mound o Other _�y�
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 �Depth of � Seeded/Sodded� Muiched �
Cell Center Cell Edges ( Topsoil �Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes O No
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Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA: � � �' 37�
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