HomeMy WebLinkAbout018-837-32-1302-SAN-2021-274 ''"`'''"'-'"``%��; PRIVATE ONSITE WASTE TREATMENT County
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�`�''="���'' INSPECTION REPORT Sanitary Permit No:
Safety and euildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a,' �a'� c.�
Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(i)(m)]
Permit Hoider's Name: ❑City ❑ Village l�Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
(bo.o ' `� o� �'�rL�- c,s�' 1�.� p 1� o�$—83?- 3� � (30�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark � . ( ` o�. ` (o�.c�
Dosing
Aeration Bldg. Sewer �-
Holding ��,�f � -7�j St/Ht inlet '�,p � q ,( `
TANK SETBACK INFORMATION St I Ht Outiet ?, 3 � 4 3,g�
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom 11•33� dx1•1'� �
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding a.-Z � JV -}- a'? N L � 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 Weil
DISPERSAL CELL INFORMATION
DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv o Aggregate
INFORMATION P I L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound a Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) � X Hole Size X Hole Observation Pipes
Length Dia _ ILength Dia Spac Spacing ❑Yes ❑ No
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SOIL COVER
Depth Over � Depth Over � Depth of— — Seeded/Sodded � Mulched
Cell Center Cell Edges j Topsoil ❑Yes ❑ No ❑Yes 0 No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes� No Io 3 0l �� I! . � - � b�j �( �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER _ oLt r.��__
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