HomeMy WebLinkAbout002-840-30-5402-SAN-2021-273 "`="T"'���„� PRIVATE ONSITE WASTE TREATMENT county
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INSPECTION REPORT Sanitary Permit No:
Safety and Bwldings Division (ATTACH TO PERMIT) 1
GENERAL INFORMATION � 1 � d���
Peisonal inYonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Hoider'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 Benchmark �, 3 ' �p�,� ' (�,o'
Dosing
Aeration Bldg. Sewer �{.2y � °I7,o6�
Holding w��e�� �� a 60o St/Ht Inlet y.3 i ' �.Qq�
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRtNTAKE
Septic NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
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 L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO ❑ Mound a Other
— -- -- — . — --— — —
DISTRIBUTION SYSTEM X Pressure Systems Only
— — ----— —--- --- -- —— —
Header I Manifold � Distribution Pipe(s) X Hole Size X H— Observation Pipes
Length Dia Length Dia Spac ___ L __ � Spacing �Yes � No
— — ----- --
SOIL COVER
-- — — — --- -—
Depth Over Depth Over — Depth of Seeded/Sodded Mulched
Cell Center Cell Edges j Topsoil_ ❑Yss ❑ No 1 ❑Yes ❑ No �
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑ Yes❑ No !a 3 �p� �Z I , / � �����
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER _______� `�_�7�__
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