028-642-17-3107-SAN-2021-402 %��<'''"'`"E^�; PRIVATE ONSITE WASTE TREATMENT county
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''=��'��`� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.� � �O�
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(rn)]
Permit Hoider's Name: ❑City ❑ Village I� 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 (y(,p Benchmark ')� ' pa.a' (ap,p�
Dosing
Aeration Bldg. Sewer 7.q� ` `j�(��
Holding St I Ht Inlet g. a-� `�Y o'
TANK SETBACK INFORMATION St I Ht Outlet �.3b ` `�3,gY `
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR WTAKE
Septic 2 � } o` h � .}a � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
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 Systems Only
Header/Manifold Distribution Pipe(sj — i 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 Mulched
Cell Center Cell Edges Topsoil _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No I�3 (O a� ___��%��-� —� v�,`' ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBEA�___�__�O�___
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