HomeMy WebLinkAbout010-941-14-3307-SAN-2021-244 �
��'' `� PRIVATE ONSITE WASTE TREATMENT county
='� °s � �S�ISTEMS SaW er
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""` INSPECTION RE�ORT
Safety and Buildings Division Sanitary Permit No:
(ATTACH TO PERMIT)
GENERAL INFORMATION �� `'
Personal infonnation you provide may be used for sccondary purposes[Privacy[aw,s. 15.04(i)(m)] � � � ���
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: - Parcel Tax No:
1 aa ' �la : � �� P�e�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �( W;e . Benchmark �� p � (� (op '
Dosing (,II�tW `;� �
Aeration � � ^ Bldg. Sewer .�k er.
5 6 � 9s g �
Holding , . St/Ht Inlet � � y� .� � 5 `�
TANK SETBACK INFORMATION . St I Ht Outlet �, � � • 5 �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic f�� } p' �g' �.�9' �q ' Dt Bottom
Dosing NA Installation
Contour
Aeration NA . Header/Man. (p,b� • �
Holding �Dist.Pipe• , �
PUMP/SIPHON INFORMATION �nfiltrative 7. 66, �.3�U
' 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 3' L y� � #of Ceils Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav �- Conv ❑ Aggregate �N �
INFORMATION P�L Bldg Well Waters � IGP � Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO '� � -} �p' p' _ N A ❑ Mound o Other � Z(� _
--- --
w�
— _ _ _ _ ---
DISTRIBUTION SYSTEM X Pressure Systems Oniy -
- - -
Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia _ �Length Dia Spac ', I Spacing ❑Yes ❑ No I
SOIL COVER
— - -- - —-
Depth Over Depth Over Depth of Seeded I Sodded Mulched �
Cell Center Cell Edges ' Topsoil � ❑Yes ❑ No ❑Yes ❑ Na
COMMENTS: (Include code discrepancies; persons present,etc.)
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Plan revision required?O Yes 0 No , , '' �� e���• �O['� ��
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Use other side for additional information Date � POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ACl01TI�NAL COMMENTS ANO SKETCH
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