HomeMy WebLinkAbout022-738-30-2101-SAN-2020-096 ,�:
"-"""`r PRIVATE ONSITE WASTE TREATMENT counry
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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 secondary purposes[Pnvacy 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 ���� �S� 5� Benchmark � �� '�07 ��
Dosing
Aeration Bldg. Sewer `1�,:;��
Holding St/Ht Inlet ���, �
TANK SETBACK INFORMATION St I Ht Outlet
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet `110.'�l 3
AIRINTAKE
Septic NA Dt Bottom �13.�?�`�
Dosing NA Installation
Contour
Aeration NA Headerl Man. �1; �� ��3.�7�
Holding Dist. Pipe .
PUMP/SIPHON INFORMATION Infiitrative
Surface �,,, \oa-•�1`�
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 1N L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate i��, ������
INFORMATION P/L Bldg Well Waters ❑ AG � Chamber Model Number:
EZFIow
CELL TO ❑ Mound o Other '�-� ��,.,�J�
--- - ----- - — —— _-- — —
DISTRIBUTION SYSTEM X Pressure Systems Only
— -- - - ,T-- --
Header/Manifold Distribution Pipe(s) X Hole Size i X Hole Observation Pipes �
Length Dia _ Length Dia _ Spac Spacing ❑Yes ❑No li
SOIL COVER
-- - - — -----—-
r Depth Over Depth Over � Depth of Seeded/Sodded Mulched 1
� Cell Center Cell Edges i Topsoil _ _ ❑Yes ❑ No ❑Yes ❑ No �
COMMENTS: (Include code discrepancies; persons present,etc.)
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Plan revision required?❑Yes ❑ No I I ' ' �"�� 1� 1
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
• AOOITIONAL COMMENTS ANO SKETCH
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