010-841-30-4203-SAN-2021-395 /�-" " . PRIVATE ONSITE WASTE TREATMENT county
i't��, �,,"\=r,
�oS �`��; SYSTEMS Sawyer
f�\����'` ( POWTS)
`'Fss'":��=� INSPECTION REPORT sanitary Permit No:
Safety and euildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 _ 3 c(S�
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#:
G�at'�- �/i�J ��.�h i�-S �o� wac-� pw'�3- t oa►o�-�ob- C
Insp BM Elev: BM Description: Parcel Tax No:
���.c7r �b�M 6�Si �I�i 6't-2.)c`[S�� A�� ��� �'O 1�-3�� �{�'�/
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�, � 3� Benchmark �,� � �o�,S3`` (on�o�
Dosing
Aeration Bldg. Sewer ,D� �S.S�"�
Holding St I Ht Inlet $.o ' �3•SS'
TANK SETBACK INFORMATION St I Ht Outlet �,,3 ' `�3.,tS�
TANK TO P/L WELL BLDG vENr To ROAD Dt I�let
AIR INTAKE
Septic ��� fi ` ,Z'7� ��-�` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 10 7S� �D•��
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Intiltrative �� �� �Q a�
Surface
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 W 3 L ;ZS' #of Cells � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters ❑ IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELLTO �-(Op ±� fi N o Mound o Other
DISTRIBUTION SYSTEM x Pressure Systems Only
Header I Manifoltl 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 1 Sodded Mulched
Ceil Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���11� 6�� ��
(
Plan revision required?�Yes � No �a �� �3 � ` � ��('� I�
Use other side for additional information Date POWTS Inspector's 5ignature Certification Number
SBD-6710(R.3/01)
AO�ITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA: oZ� -- �4.�
' 1
� �\��
�
_ _ , _ ._ : _ _;_ _._.. _ , _.�
, — -,..- ..._ _ —.._... - _ .. _.. _ _ _..
__: ._.__ .�
O ;
, , . .. ; �
� � �`IS` �5����..�
: . i a�, - . ,
_ � _ : , � _
. : � ;
; �
,- -- _.__ ._
. ___ . .
_.
,
. : . . . . . ..... . . ... . .....y. ...:.... � .........._._ ..._'
. ' . . . ,. � . . _' ....,
. 1 . • .. •. . . . . . ... , .
; , 2�� , O 1Y� � . .
. ._ __.
�o
:_ _ ._ ; N�� d �
' ��e�r'
. 3?.t�
,,,��.;I'.
�
�� �
e��'
���9
�
��
�
�l ��s�-r�
�—
�_ �D �,,�p/jQ,.�q�(�I t'
or — -