HomeMy WebLinkAbout002-106-14-1500-SAN-2021-026 %�""'''=""``��� PRIVATE ONSITE WASTE TREATMENT county
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INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a � — d��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. l 5.04(1)(m)J
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 Benchmark 3,'7
/c�3.'7 00,d
Dosing
Aeration Bldg. Sewer �
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Holding �,�,� 6� St/Ht Inlet (,.�.�, � °�`�, $
TANK SETBACK INFORMATION St/Ht outlet (,,c{S' .�-'
TANK TO P/L WELL BLDG vENr10 ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding -�(o� �- � � � Dist. Pipe
PUMP/31PHON INFORMATION Infl�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 � #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
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DISTRIBUTION SYSTEM x Pressure Systems Only
CHeader I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length _ _Dia Spac ; _ Spacing ❑Yes ❑ No
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SOIL COVER __ __
�CDepth Over Depth Over Depth of Seeded!Sodded Mulched
ell Center I Cell Edges �psoil T ❑Yes ❑ No �0 Yes ❑ fJo
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑Yes❑ No �� �� �i� " � l�`��(�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
AOOITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA� �I - �-�o
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