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028-642-36-4101-SAN-2021-423 ''""='"'-'"`%� PRIVATE ONSITE WASTE TREATMENT county �r �2�� \� SYSTEMS ';�., ��! �SPs �� Sawyer `�> "� ( POWTS) �� y`��' ''-��V,'-' INSPECTION REPOR? sanitary Permit rvo: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION � � — K�3 Peisonal infonnation you provide may be used for secondary putposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: �a,n L�1�O./� 1��t� �_ Insp BM Elev: BM Description: Parcel Tax No: r �� '� ,1 v.�. ov� .a-QT' 0�'�—6`{-Z r �b ' � `D � TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �,,,��e�T '3 ap o d- 3�-0 Benchmark �pp,o� DOSing << ��j �'�}-{'T'o.,.�` 9)�7 Aeration Bldg. Sewer Q��3 � Holding St/I�Inlet 9 S,O` TANK SETBACK INFORMATION Stl Outlet `1H,9S' TANK TO P/L WELL BLDG AiR iNT°KE ROAD Dt Inlet g$,Q ` Septic .F� ,,�,` +,�c' .�e,' NA Dt Bottom $S$� 9 � , � � Instaliation Dosin � �b � �p NA Contour Aeration NA Header/Man. q 1.7�' Holding Dist. Pipe PUMP/SIPHON INFORMATION �nfiltrative o� , Surface `� � Manufacturer Demand Final Grade Model Number GPM TDH �� Lift Friction Loss Sys Head TDH Ft Forcemain L � b` Dia �'� Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W 3� � � #of Celis Type of System Distribution Media Manufacturer: � Conv ❑ Aggregate �S SETBACK P I L Bldg Well OHWM of Nav � �GP � Chamber " INFORMATION Waters � AG � EZFIow Model Number: CELL TO .r-�' '� �D' �t/ ❑ Mound o Other �� - ——--- —_ _---- DISTRIBUTION SYSTEM X Pressure Systems Only Header 1 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 —�Topsoil _ _ __� ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) �.�,.,�1�-� S( t� 1�2 Plan revision required?�Yes ❑ No p� '6 23 I ��- --� �j�� I_ Use other sitle for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AOOITIONAL COMMENTS AND SKETCH SANITAAY PEAMIT NUMBEA: � � " ��-3 ��, x�y �7 �� e�-��,�� . � �'°9 ►1 ' _ � �/� � _ ; _ �$�,r, — -- — — �� 3 � � ��-�— : . __ ' : , . . J , �, , , , , . __- - _._ __.___ r _:_ �----_' - -- - - - - • -.,__ _ , , . . : .�. ._... . ... A ...r. . ...._. ... ......... .:. . . . . . . .. .... .. .. . . ...j..._ _......_�. .. . �� . . . ..��, . . \��C' �� ,� P��1fio CA\O� '�(, � , � � � � � p� t1 �L \ �,�-ap D Wl�� v; �� \C°�' �, �5fl � � �-�� y� �-r. � ��, �:✓vl. ��a � � -a � J7 \ \ �\ � � .� � �j Qyx �r� � M