010-145-00-0203-SAN-2021-394 '"""'"0.'-""<``�� PRIVATE ONSITE WASTE TREATMENT county
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`r's'—°�"='' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � I _, 3q�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Viilage �,Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,N i�r- ��oc c'� Bench mark �p��o �
Dosing ,,,,;��- �SD
Aeration Bldg. Sewer � , �
Holding St/Ht Inlet 8a ,�g'
TANK SETBACK INFORMATION St I Ht Outlet 0.33 �
TANK TO P/L WELL BLDG IRINTA�KE ROAD Dt Inlet go.�� '
Septic +S � .t-�' ,}{�� .�.� � NA Dt Bottom �,Q�`
� • Installation
Dosing �s a.-� �,�5.� �s� NA Contour
Aeration NA Heacler I Man. 9 s;S �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �,Y,S� c
Surface
Manufacturer Q � Demand Final Grade
Model Number } � �PM �{; ��. ��,o$ ►
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TD Lift Friction Loss Sys Head TDH Ft
Forcemain L fi�po� Dia �" Dist.To Weli
DISPERSAL CELL INFORMATION
DIMENSIONS W 3 L t� ` � #of Cells �j Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate ^ �
SETBACK OHWM of Nav � � I�
INFORMATION P I L Bidg Well Waters � GP �c Chamber Model Number:
❑ EZFIow
CELL TO �1S ov� �6D� cso` ❑ Mound o Other �Y,�,
_____------ ----
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipe�
Length Dia Length _ Dia Spac _ Spacing ❑Yes ❑ No
--- - - -- --
SOIL COVER
_ ---- __ _--- -- _
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center I Cell Edges Topsoil___ __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No �� ` 6 a� � � ��'��� �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: oZ � 4 �_
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