014-268-00-3400-SAN-2021-380 -'�t''R'"��� PRIVATE ONSITE WASTE TREATMENT county
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""���" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ 3'g�
Petsonal infonnation you provide may be used for secondaty purposes[Privacy Law.s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �,Town of: j State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
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QO�D Kati i., a..�l'�Q OI�-(�-'e�-b -00 —3`{00
TANK INFORMAT ON ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�,� ,�- 3� Benchmark ��;�` (dl,�$` (b�.�'
Dosing
Aeration Bldg. Sewer S•2$`� �(�.0 3'
Holding St/Ht Iniet S Y�� .a 3�
TANK SETBACK INFORMATION St I Ht Outlet S; S' '- �5�;7 '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Iniet
AIRINTAKE
Septic �St,' N +S� � NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header I Man. �� �(5,��
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION �nfiitrative � �
Surface 6 '�g 1�(..S
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 � #of Cells Type of System Disl:ribution Media Manufacturer:
SETBACK OHWM of Nav � Conv o Aggregate
INFORMATION P/L Bldg Weil Waters ❑ IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO � �(p` �v /U o Mound � Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifold Distribution Pipe(s) i X Hole Size X Hole Observation Pipes
Length Dia Length Dia _Spac j __ Spacing ❑Yes ❑ No
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched �
Cell Center Ceil Edges Topsoil_ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision required?❑ Yes O No p3 �D 1 �2 ;� J��^ � 6cr � �(�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS AND SKETCH
SANITAAY PERMIT NlJMBER:____�._��O _
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