010-298-00-0200-SAN-2021-413 � "'"f�� PRIVATE ONSITE WASTE TREATMENT county
+>�y��a SYSTEMS Sawyer
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�.���a�s� :� ( POWTS)
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INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �2` , t-((3
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 ' !p � ' (po,p �
Dosing
Aeration Bldg. Sewer -
Holding St/Ht Inlet -
TANK SETBACK INFORMATION St I Ht Outlet �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom (9 9S� �� o Ir
Dosing NA Installation
Contour
Aeration NA Header/Man. �,Y ' �i'7,S
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative S.Y6 � 46.� �
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 ❑ �4ggregate
INFORMATION P I L Bldg Well Waters °� GP ❑ Chamber Model Number:
a EZFIow
CELL TO ❑ Mound � Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) � X Hole Size X Hole Observation Pipes '�
Length Dia Length Dia Spac � Spacing ❑Yes ❑ No_J
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 O No i o3 lo a-�2 � ^ � �`j �(�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
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