HomeMy WebLinkAbout032-539-10-4412-SAN-2021-294 ��'�'"E` � PRIVATE ONSITE WASTE TREATMENT county
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°RFSS'�'-�`'=-:' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� � �� �,/
Personal infonnation you provide may be used for secondary pu�poses[Privacy Law,s. 15.04(1)(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:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �,a g �a,2,c�$� �oo.o�
Dosing
Aeration Bldg. Sewer s-r �'
Holding 5 (�sb 7� St/Ht Inlet ,�( ' c�$'
TANK SETBACK INFORMATION St!Ht Outlet �:35' ,�3'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom 9 ys ' S , '
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding �I�,S'� /�/ �3 -�-�3� �S' Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Motlel 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/L Bidg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound � Other
-- - --- -------_--------
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(sj -- X Hole Size X Hole Observation Pipes�
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
SOIL COVER
-- _ -- -- —
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center I Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?0 Yes❑ No �� p$ �3 � — 6q� r� �
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Use other side for additional information Date POWTS Inspec or's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS AND SKETCH
SANITAAY PEAMIT NUMBEA: ��- ���
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