028-220-00-0100-SAN-2021-388 '"""""'`'""�:; PRIVATE ONSITE WASTE TREATMENT County
,,,,
,�Y� �S' SYSTEMS Sawyer
�� � s � ( POWTSj
��`�' �'��^ '� INSPECTION REPORT sanitary Permit No:
Safety and Buddings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a, �, '1J�
Personal inYonnation you provide may be used for secondary pu�poses[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
5��,�, ��� pDh� ��a�,- �I�
Insp BM Elev: BM Description: Parcel Tax No:
do.� � s�1 ����.�s��b oag-2�0 -oo -o,00
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�„e�- 1(oYS Benchmark �pc�,o''
Dosing •e. � Oo c7 j� � ' 4 y3,s'
Aeration Bidg. Sewer� `�Y•8S�
Holding St/Ht Inlet �2�S'
TANK SETBACK INFORMATION St I Ht Outlet q�,� �
TANK TO PIL WELL BLDG AiR iNr°KE ROAD Dt Inlet q 1,�?'�'
Septic �-�� r}-„ts� �{S' �-? � NA Dt Bottom ��, �(,S �
Dosing � � � � NA Installation
��S -r�.s "� '�'S Contour
Aeration NA Header/Man. 9 7_os'
Holding Dist.Pipe
PUMP/SIPHON INFORMATION Infiltrative y6,3q �
Surface
Manufacturer t Demand Final Grade
Model Number �g GPM i P�`• 97.SS�
TDH (c Lift Friction Loss Sys Head TDH Ft
Forcemain L �'7�p Dia �.�� Dist.To Well
DISPERSAL CELL INF RM TION
DIMENSIONS W L � gp` � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P/L Bltlg Well Waters ° G ❑ Chamber Model Number:
� EZFIow
CELL TO �(o .+-(p fi� �-� ❑ Mound o Other
— -- - --_ -- -- - --- -- ---- -__ _
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pi e s - �
p ( ) X Hole Size X Hole Observation Pipes
Len th Dia Len th Dia S ac I Spacing ❑Yes ❑No
9 9 _ p
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched �
Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
�,�5��(�,l i��l� � 2 I
��
Plan revision required?�Yes ❑ No �3 !o� �� / 6-�j��,�,
' -- �_- _��W � - -----�'
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA ____��_3� ____ ^� �I ^- �_
�� �/UL
�i
� �
��
, 6� � 3 �S-
_ ,—
�D �
. �\�ab / /
�p�� `( � -
� `�'N �' I . .,. . .
. �\�� `/� ��,Sk����1�Vf. ... . . . . . .
� �
� � � ��'' �
/ -�- ��r�� \� 2a' �
/� �o' g�
� 5� 1 I
� y �
� 3't,Kc�
�� �Q��
�I
�(
�' �
� � �, � �p�3a�
�..�° ;
CS° - - _ `
l7'�) ! �f��,�� �
►
_ _ _ `�a 5�,�,�, .
��n.
���.5
��.�'
�Pd--
�--