HomeMy WebLinkAbout028-642-20-4107-SAN-2021-020 �;�=�"''�`""`:�-;r\ PRIVATE ONSITE WASTE TREATMENT County
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�\��Srs J.?'' ( POWTS)
�°r`'"`''`'�p� INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � I ^ O'��
Personal infonnation you provide may be used for secondary purposes[Privacy La�v,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village Q`Town of: State Plan Transaction ID#:
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Insp BM Elev: B Description: Parcel Tax No:
o���Y.1-�'c.f(o�7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,..,�¢,�.c�r- �000 Benchmark
Dosing co...,,bb 6o�c
Aeration Bldg. Sewer y,( '
Holding St/Ht Inlet �,.$,L r
TANK SETBACK INFORMATION St/Ht outlet --
TANK TO P/L WELL BLDG vENTro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom (O •,3 �
Dosing NA Installation
Contour
Aeration NA Header/Man,
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer �q�, � Demand Final Grade
Model Number �- GPM e�,,,�4,,,, ,2.�7 f
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG o EZFIow
CELL TO �( Mound o Other
--- ---- —. _ -- __ _ __ _
DISTRIBUTION SYSTEM X Pressure Systems Only
-- — ___ -- ----- .
Header/Manifold Distribution Pipe(s) X eolH Size X Hole Observation Pipe.�
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.)
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—-- - — -------- --
Plan revision required?�Yes � No p j ,�2 �� " � ��� �� �
Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBER: �I - ���
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