004-839-08-5214-SAN-2021-417 J/I,� ``'> PRIVATE ONSITE WASTE TREATMENT county
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""'"�'"'' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � I � � � 7
Personal infonnation you provide may be used for secondary 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:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � pa p Benchmark _ �,�' �'�,7s� (0�,0�
Dosing
Aeration Bldg. Sewer �(,�� � �
Holding St I Ht Inlet .�;3 �l •Y �
TANK SETBACK INFORMATION St/Ht Outlet �,�� 9 ��-'
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic $� �Sb� I S� �1-1 S ` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header!Man. (,.`� q ,g�
Holtling Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �, t �
Surface ?' `Ib.B�
Manufacturer Demand Final Grade
Motlel Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W 3 I L � �'g #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate � l �
INFORMATION P I L Bldg We�� Waters � GP � Chamber Motlel Number:
❑ EZFIow
CELL TO �� �- �� �7S� ,�. �p ❑ Mound o Other n��
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifold Distribution Pipe(s) �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 l Cell Edges Topsoil _ �— ❑Yes ❑ No � ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present, etc.)
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Pian revision required?O Yes ❑ No (} j �'' 2 3 �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT NUMBEA: o2I- K��
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