008-937-08-5214-SAN-2023-104 � "�'"E�r PRIVATE ONSITE WASTE TREATMENT county
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- � oS SYSTEMS Sawyer
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��' ""'`� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �'�.- lQ�
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village l�Town of: State Plan Transaction ID#:
�i-2� ,�. r-2.`p eCGct �c1T�—�lS� �^ ��
Insp BM Elev: BM Description: Parcel Tax No:
If�O.� `�O �,T- �,� t�S�' `� 0�$- l�'3� r C�g�'.2 l
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark (op,o �
Dosing
Aeration Bldg. Sewer �7,Y'�'
Holding Gv�Q..�f- �o� �-{D L� St/Ht Inlet �7.((, �
TANK SETBACK INFORMATION St/Ht outlet �16.$Q
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding .p{oa �cob g �t-$ Dist. Pipe
PUMP 1 SIPHON INFORMATION Infi�trative
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 L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
-----_ -- -- ---- ____-- _-_--_—
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) % X Hole Size X Hole Observation Pipe�
Length Dia ] Length Dia Spac ! Spacing ❑Yes ❑ No _ j
SOIL COVER
-- -- ----- - - — -
Depth Over Depth Over h of Seeded/Sodded Mulched
� Cell Center ( Cell Edges j Topsoil __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑Yes❑ No �� , �
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�0 3 0� ��Y; ��--- ` � - ---� ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL C�MMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA:___�.3���__
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