HomeMy WebLinkAbout010-941-26-2125-SAN-2021-018 ,
`�""`� PRIVATE ONSITE WASTE TREATMENT counry
;'�:�sP$ = SYSTEMS SaW er
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( POWTS) y
''"""`''� INSPECTION REPORT
Safety and Buildings'�'Division , Sanitary Permit No:
. , (ATTACH TO PERMIT)
GENERAL INFORMATlON w I _��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l) )J
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�n L•, (�„rt�-
Insp BM Elev: BM Description: Parcel Tax No:
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1"
' ' TA�V�( INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic V„.Y k�- ���� Benchmark
Dosing' • �� .6 �oo'
Aeration Bldg. Sewer
6•03 .��
Holding St/Ht Inlet V. 5� 6 ?>7
TANK SETBACK INFORMATION " - � St/Ht Outlet (p. S �
TANK TO P/L WELL $�,p� vENr ro� �ROAD' Dt Inlet �
AIR INTAKE
Septic �` � ' � -� S � NA Dt Bottom
Dosing ` . �A Installation�
ContouE
Aera�ion ' � NA Header/Man. ` 6$ S
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION � �nfiltrative q,yq n`I,)3
Surface 0 �
Manufacturer Demand Final Grade
Model Number GPM �
TDH Lift Friction Loss Sys e TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION . .
DIMENSIONS W L � #of Celis� Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav �' Conv ❑ Aggregate `N �
INFORMATION P�� Bidg Well Waters � IGP t2 Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO � �- � f ❑ Mound � Other �G�
__--
__-3 _ - �? --` 9►� NA C?...
-----_ _- ----- - -
_ --- - -__
I TRI UTION SYSTEM X Pressure Systems Only
9 9 pO P , X Hole Observation Pipes
Header I Manifold �Distribution Pi e s X Hole Size �, Spacing ❑Yes ❑ No '�
Len th Dia Len th Dia __ S ac I,
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.)
� ;�5�-�-��e� ��y ��l .
_� _� ,--
Plan revision required?�Yes❑ No ' �i i �I � '��� �OZ��k•JI i
' ,, ' ��38�9
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3l01)
A�OITIDNAL COMMENTS ANO SK TCH
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