HomeMy WebLinkAbout020-638-07-2201-SAN-2021-196 /�- ' ` > PRIVATE ONSITE WASTE TREATMENT county
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F'""-�'"�` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division
(ATTACH TO PERMIT)
GENERAL INFORMATION � l - I�Cp
Personai infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
l�o.a ' '� ��- NT �'��r-�� b�-63�-0?—�� j
TANK INF RMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark 3,t;2� ��,�1 �C�a,�'
Dosing
Aeration Bldg. Sewer S o r �g,���
Holding SGc.�}�.r 3� St/Ht Inlet b �RY ` �6,�g '
TANK SETBACK INFORMATION St/Ht Outlet
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 .�(cp' }�� �-�.c�� -�-�-0� ��.S' Dist. Pipe
PUMP 1 SIPHON INFORMATION Inflitrative
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 Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO o Mound o Other
- -- -- -_ --— —
DISTRIBUTION SYSTEM X Pressure Systems Only
-- --- -- -- --
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia l Length Dia Spac Spacing ❑Yes ❑ No
--- ---
SOIL COVER
[ Depth Over Depth Over Depth of Seeded/Sodded Mulched
Celi Center 1 Cell Edges Topsoil_ __ � ❑Yes ❑ No 1 ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision requiretl?�Yes � No �� pg 23 � � _� �j�,��j �� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: ��^ �(o
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