028-742-27-5113-SAN-2021-391 -'�`=�'"'-`"'�`:%;;; PRIVATE ONSITE WASTE TREATMENT county
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�����o SYSTEMS Sawyer
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INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 � �q r
Peisonal infonnation you provide may be used for secondary purposes[Privacy I.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
���-� ` � a� �...e.l o�$ -�7Y� - �? � s�� 3
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic N,�.e _ �O�o Benchmark �pp,��
DOSIng —cow�op bn�
Aeration Bldg. Sewer ��$.o '
Holding St/Ht inlet $�38�
TANK SETBACK INFORMATION Stl Ht 0utlet �8,og'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic �� 'k3S` %35� 3r NA Dt Bottom �5.�3�
Dosing u •� �. �� NA Installation
Contour
Aeration NA Header I Man. �'0.O�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface �1�0�
Manufacturer Demand Final Grade
Model Number L��S GPM ; � � . 9�,o r
TDH (� Lift Friction Loss Sys Head TDH Ft
Forcemain L �� � Dia �y Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W 3 � �6 6' / #of Cells Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate `��l
SETBACK P I L Bldg Well OHWM of Nav � IGP ,� Chamber �
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO .#-�__ �p � .f-�_ ❑ Mound � Other Qy�
--- -- — - -— —_
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I 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 I Mulched �
Ceil Center Cell Edges I Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes❑ No !� � � S
� 03 09 a 2 �_ �� � __J �� 6 (�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBER: _�_�l 3�__
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