024-741-35-3326-SAN-2021-407 '�'`-`=""T"``��� PRIVATE ONSITE WASTE TREATMENT county
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z �� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a� �- Y��
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �,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 ,,,,�� � �� Benchmark -O�S'� q9.S'� (c�o•o'
Dosing
Aeration Bidg. Sewer 3.( ' " q 6. �
Holding St/Ht Inlet S S ' �Y.b'
TANK SETBACK INFORMATION St I Ht Outlet s,7 y � 4 3_�6 '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic ,}. ` +�oo }.25� 'F�o�-S� NA Dt Bottom
Dosing ' NA Installation
Contour
Aeration NA Header I Man. �.a � q�,S �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative , ,
Surface 9.a �(�,�-
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 C} � #of Cells ,2 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��I,
INFORMATION P I L Bldg Well Waters � GP �. Chamber Model Number:
❑ EZFIow
❑ Other
CELL TO =1-l�0 �} �� �-� ❑ Mound 4y�-�
-- — __ _— _ —-- — ------------
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) 1 X Hole Size X Hole Observation Pipes
Length Dia Length Dia __ _ Spac ____ _ I Spacing ❑Yes ❑No
SOIL COVER
De th Over De th Over I Depth of Seeded/Sodded Mulched
Cell Center � Cel�l Edges � Topsoil —��Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes 0 No �3 �p a.� 'I ' � �? ���
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER ___a-�� �4� __ �
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