014-942-29-1107-SAN-2021-414 %;;t`�'"'-"t�>; PRIVATE ONSITE WASTE TREATMENT County
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�""',����^-�''' INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT) �,/
GENERAL INFORMATION � , - [ � /
Personal infonnation you provide may be used for se�ondary purposes[Privacy Law,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:
��a.�' �►a� ��b�,��, �'�, r�'5,�. 36" n� �� ��_9�r� - ��- rro-7
TANK INFORMA'TION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic wi,ed eJ — �KO Benchmark �.�,l � loi.6!� loo�o�
Dosing -c�,...,��, 5�t�
Aeration Bldg. Sewer '- �
Holding St/Ht Inlet -
TANK SETBACK INFORMATION St/Ht Outlet b�•3� 9'3�3 r'
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet �'.3S �3, �
AIR INTAKE
Septic ��.$` ��(S ` �2S� ��S � NA Dt Bottom � 2,Y�!-� �9, (9 r
Dosing u 4 �� �� NA Installation
Contour
Aeration NA Header/Man. b,g3 � q �-� '
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Surf cte e 7.61 � `TY.��
Manufacturer ti2,,.e`�- Demand Final Grade
Model Number �j$ GPM {-�i '�• 6�o`f `�S.S?,
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L �� Dia ;1'` Dist.To Well
DISPERSAL CELL INFORMAT ON
DIMENSIONS W 'J L o o� �� #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav i�. Conv ❑ Aggregate
P/L Bidg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO .}-S' k�' �qo� ❑ Mound o Other
-- ----
- . ___ _ --- ------- --- --
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
-_ -- -- -__
SOIL COVER
Depth Over Depth Over � Depth of Seeded/Sodded Mulched
Cell Center Cell Edges i Topsoil_ ❑Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes❑ No I�p-� j �p 2a � � � � ��j� '�
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Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
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