HomeMy WebLinkAbout014-941-09-2210-SAN-2021-202 -,,__�"T'� PRIVATE ONSITE WASTE TREATMENT county
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�E;s"°-�'"-'' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a 1 .— �C7a
Personal infbnnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Pian 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 U,�� �p Benchmark �,3 3 ' oa 33� n�•��
Dosing
Aeration Bldg. Sewer �',o�� `( 31�
Holdin St/Ht Inlet ,
9 (, .08 ` ,aS
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AI R I NTAKE
Septic }�� � �. -�' �-'� ' NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. 6�33' R.b,o�
Holding Dist. Pipe
PUMP I�IPHON INFORMATION Inflttrative
Surface 733 � qS� �
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 3' L g$ ,.,�p` #of Cells Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate �I
SETBACK P I L Bldg Well OHWM of Nav � �GP Chamber \�
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO �-�O` �. p ,}-�� ❑ Mound o Other QY�
DISTRIBUTION SYSTEM � X Pressure Systems Onry
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia_ Spac _ Spacing ❑Yes ❑ No �
SOIL COVER
-- - _ _ - — - ---- ---
Depth Over l Depth Over ( Depth of Seeded/Sodded Mulched �
Cell Center � Cell Edges (_Topsoil___ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inclutle code discrepancies, persons present,etc.)
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Plan revision required?❑ Yes ❑ No
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL C�MMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: �I''o2�a
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