HomeMy WebLinkAbout010-941-26-2124-SAN-2021-292 -"„t`='"'''E�;, PRIVATE ONSITE WASTE TREATMENT county
>���'
��"� �� SYSTEMS
�-� � '�s '�' S awyer
��,� �s ( POWTS)
, � ,.�
��` ' '����� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a� ��a��
Peisonal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
� �`�v1 \R- l.G `,�G c'(�� a �^+4 ra
Insp BM Elev: BM escription: Parcel Tax No:
oo.� ' Iva►1 �-n`b�v�� 3�'' �, o �-Y'' � -�;..� oi�—�Y(—�6- � ��Y
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,� bfl� Benchmark O ,��f� l O�.7Y (Go.�'
Dosing
Aeration Bldg. Sewer �'.3 ' � ,Y
Holding St/Ht Inlet � � qS' p'
TANKSETBACK INFORMATION St/Htoutlet S'.�7` C{ ,�? '
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIRINTAKE
Septic �1-� ` {V '���` ��S` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. (, ,o 3 ' 9 ,71�
Holding Dist.Pipe
PUMP/SIPHON INFORMATION �nfi�trative , �
Surface $•2S ��.�(R
Manufacturer Demand Final Grade
Model Number GPM .-
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS W 3 � � (��� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P�L Bldg Weli Waters °� GP � Chamber �
❑ EZFIow Model Number:
CELL TO ��.S -1-lo �/ � __ � ❑ Mound o Other y� —
----- — - - - --------
DISTRIBUTION SYS EM X Pressure Systems Only
-- ------- --- -- __ __ --
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes�
Length Dia Length Dia Spac � I Spacing �Yes ❑ No
— ---- —---
--- -- —
SOIL COVER
--__--- ---- _-- —
Depth Over Depth Over ! Depth of Seeded I Sodded Mulched
9 � To soil ❑Yes ❑ No ❑Yes ❑ No
Cell Center Cell Ed es p _____ 1 1
COMMENTS: (Include code discrepancies, persons present,etc.)
��,s�I I� l bl �31 a- �
; �-- /'
-- ----_ ---
Plan revision required?❑ Yes❑ No ��3 03 2� I _`5 / I (�G J b� /
lv i b
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS ANO SKETCN
SANITARY PEAMIT NUMBER:_ _c2� ___��__
L> C,�
D o
t
��s ���
� ��d�, s ,�g�
� ' ,
3� . 3 �, y• _ . : .
,�,;�
, . 1�Joo�
gN�.�, �. �fS -'� �, �,.,��7
O �A` .,� �,
.
�o t��
• �' 1.
_ \
�
�
�
��� �
�o
��\
S �'""`
� a
� �
�—
sc -