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028-278-00-0700-SAN-2021-386 �-�T`` PRIVATE ONSITE WASTE TREATMENT county /�"�'_� "'=`. i� ; o '�;�: , � ��ps,� ��� SYSTEMS SaWyer �� ��/ ( ) \�y'��ss'"-�`'`' INSPECT ON REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION a I ,_ ��� Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J Permit Holder's Name: ❑City ❑ Village �,Town of: State Plan Transaction ID#: JrT c,h V"l c.l7,i n �j ��.r- (�c,l[-�2� r— Insp BM Elev: BM Description: Parcel Tax No: lo��c� � � a� �e� oa�- a�B-�o��-?� TANK INFORMATI N ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �„��e �� Benchmark �p�,o' Dosing Aeration Bldg. Sewer q�(,� ` Holding St l Ht Inlet Q3 ' TANK SETBACK INFORMATION St/Ht Outlet Q 3,y � TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet AIR INTAKE Septic .}-�� �' �, � .{-�i NA Dt Bottom Dosing NA Installation Contour Aeration NA Header I Man. �1�,�' Holding Dist. Pipe PUMP/SIPHON INFORMATION Infiltrative , Surface �l•� Manufacturer Demand Final Grade Model Number GPM TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist. To Well DISPERSAL CELL INFOR ATI N DIMENSIONS W 3 L t,f y y' ! #of Cells3 Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate ��`I INFORMATION P/L Bldg Well Waters o GP � Chamber Model Number: � ❑ EZFIow CELL TO �1-S' •y-� �$b' �h(oo � ❑ Mound o Other QY fi _ _ _-- ---- - — ._ --- 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 � Mulched � Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ PJo COMMENTS: (Include code discrepancies, persons present,etc.) � ��l(� � S 1. _ ��-lg I�I �-�• - �"� �6�2� Plan revision required?�Yes � No iD� �s �3 �--1��`' --- ���(� Use other sitle for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A��ITIONAL COMMENTS ANO SKETCH SANITAAY PEAMIT NUMBEA: �1 ^ 3�'�0 �fl ��y� l�� ___-_ -� --..�_ . _ _ ' _ - -- _ � __+.-- _-�_ _-�_ ..__ . , ... , O�-G`� _ _;_ . _ . . _�.. .. . ;._'_ � �._.. ..;_. , i ��, �. . ,. . .. : •. __... .'. ._. . . . � . . .�........ _. __.. � . .. ..... .._.., � . ..._. . .... ._... : . ,., 1 ....... i ..:_ .... _.p_ .. t . . . , . � � � i . . I . . �_ ; . . : , 3��< . ;__ -..-._ :.._ _ . - - - -- , � � : _ __'. ... : . . _ .: _ .__ _ - - - - - � 0 _ _ 1 GtC��. � , w,� g,�n, 6� , `7�� 4�'�g`� � �N 1 � � � �(S� � � i �� �- i � O C"' �' _ C`' • - - Qt nl � �2�r� �n��� s�- �� �9 ���� � � Qa �� � -�— . , —Pd--