026-939-12-5306-SAN-2021-400 '"�`-'"T"`�� PRIVATE ONSITE WASTE TREATMENT county
����a SYSTEMS Sawyer
`��,��aps, ( POWTS)
\`�!i-a�.in.�r�.'�r%.
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � ., YOc�
Personaf infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
�c+ln..�s �' �� �0�� �aK ��t� �
Insp BM Elev: BM Description: Parcel Tax No:
�oo.o ' �13�� c��- o� h.��� S�✓ o�b- R39' - l� �3'30�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,��- �,�� Benchmark ,3S � fal.3S� (o�,e �
Dosing
Aeration Bldg. Sewer '7 ' q T'�r
Holding St I Ht Inlet 3,�j � q7,K �
TANK SETBACK INFORMATION St I Ht Out�et �,o ' q-7 '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic �cS` �ZS' S' .f.S� NA Dt Bottom
Dosing NA Instailation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative
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 � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure��ystems Only
Header/Manifoid Distnbution Pipe(s) X Hole Size X Hole Observation Pipes �I
Length Dia Length Dia Spac Spacing ❑Yes 0 No
--__ -----_ -- --- ------ - J
SOIL COVER _
Depth Over Depth Over '� Depth of � Seeded I Sodded � Mulched
Cell Center Cell Edges � Topsoil ❑Yes ❑ No �Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
���/�� ��( � l� l
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-- —� �
Plan revision re uired?O Yes❑ No / /
q a3 69 a _ ' � _ ; C��� b
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER:____.�,-_�OO _ _ _
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