HomeMy WebLinkAbout010-941-26-2123-SAN-2021-293 -'""-'"'''E^%' PRIVATE ONSITE WASTE TREATMENT County
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INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �. 1 _ a93
Personal infonnation you provide may be used for secondary purposes[Privacy Law,;. I 5.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
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insp BM Elev: M Description: Parcel Tax No:
po.� Na,�,o- r;���, 36�� u .S- s;�. � �,� I� oto -9Y�—�6 — �113
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,�,�� � cR�O Benchmark D.(;S� oo.�S� oo.t��
Dosing
Aeration Bldg. Sewer y,$' �j�;8�-'�
Holding St/Ht Inlet s',�S � �s o�
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TANK SETBACK INFORMATION St/Ht Outlet S",g3' Q�,$,2�
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ��� N �15� �� � NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. .S�$? 4�j,7$'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface 7��5� �2,7�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO MATION
DIMENSIONS W 3 � $ #of Cells Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate
SETBACK P I L Bldg Well OHWM of Nav � IGP � Chamber �` �
iNFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO k ' 3l S N ❑ Mound o Other Y�
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia _ _I Length Dia _ _ _ Spac _� _ I Spacing ❑Yes ❑ No
SOIL COVER
-- -
Depth Over T Depth Over 1 Depth of Seeded/Sodded � Mulched
Cell Center � Ceil Edges I Topsoil _ ___ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required7�Yes � No � � , �j�j ��
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBEA:__�1._�4,3 __
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