HomeMy WebLinkAbout012-740-09-1403-SAN-2021-211 ��=�"T'`� PRIVATE ONSITE WASTE TREATMENT �ounty
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{�4\�SP$ `�� SYSTEMS Sawyer
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`>s�'—°V�=' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION o� I — a I �
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(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 �j — � a.�'F� Benchmark
Dosing _ � Ne.,� Rv�'1 �,tS ����(S� (oa.c� �
Aeration Bldg. Sewer 3• YS� �1g•�7�
Holding St I Ht Inlet S`, � � ps-'
TANK SETBACK INFORMATION St I Ht Outlet .r 3 � `�6 S'
TANK TO P/L WELL BLDG vEr,r ro ROAD Dt Inlet
AIRINTAKE
Septic �j` N 1S� S� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 6,S( � 9��6Y r
Holding Dist. Pipe
PUMP I 51PHON INFORMATION Infiltrative � q ,
Surface 7�S ���S
Manufacturer Demand Final Grade [-�_� �?� �
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weli
DISPERSAL CELL INFORM TION
DIMENSIONS `N 3' L gs ` #of Cells Type of System Distribution Media Ma�ufacturer:
SETBACK OHWM of Nav 11� Conv ❑ Aggregate ���
P I L Bldg Well ❑ IGP Chamber Model Number:
INFORMATION Waters � AG �
❑ EZFIow
CELL TO .�' �-� N �/ ❑ Mound o Other �(�C 3�
-_ _ _ ----- -- - ---
DISTRIBUTION SYSTEM X Pressure Systems Only
-- -----_ _ _
Header/Manifold j 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 I Depth of Seeded/Sodded Mulched
Cell Center Cell Edges I_Topsoil � ❑Yes ❑ No � ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes ❑ No o� �� �3 � �w b9 � !�
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Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT Nl1MBEA: �I�02) (
: �$�
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