HomeMy WebLinkAbout024-741-08-5107-SAN-2021-296 �;t'-''"'`"`<�> PRIVATE ONSITE WASTE TREATMENT county
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p$ '� ( POWTS)
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�' ��'�'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � ` ��q�
Personal inYonnatio�you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
,.. � 1J�+�nq� Ta� E� 'ICvH�.� Lc+�- �
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 �� � .- ab Benchmark �„a,s o�.a$ � (oO.a�
Dosing - G6,••,� b 7� -
Aeration Bldg. Sewer
Holding St/Ht Inlet -
TANK SETBACK INFORMATION St I Ht Outlet
TANK TO P/L WELL BLDG AIR NTA�KE ROAD �t� � �(,a ' °t��,g-'
Septic NA Dt Bottom �.(�, � �3,p��
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe S''•s' q�;�S'
PUMP 1 SIPHON INFORMATION Surface e 6�6� 9y,s 1
Manufacturer �f-. Demand Final Grade
ModelNumber �'Q GPM G33 S'7S� `j'S�S�
TDH �f.�Lift Friction Loss Sys Head TDH Ft
Forcemain L � Dia " Dist.To Well
DISPERS CELL INFO M TION
DIMENSIONS W .,LS L #of Cells Type of System Distr�bution Media Manufacturer:
SETBACK OHWM of Nav j� Conv ❑ Aggregate �eo f'�'14 fi
INFORMATION P I L Bldg Wel! Waters � IGP ❑ Chamber
❑ AG a EZFIow Model Number:
CELLTO fi7 �-7S' � �-�o� ,r��' _ ❑ Mound �' Other
— - ----- — — _--- —
____ _
DISTRIBUTION SYSTEM X Pressure Systems Only
-- ---------- — _-------- ---------
Header/Manifoid Distribution Pipe(s) X Hole Size X Hole Observation Pipes i
Length Dia Length Dia Spac 1__ Spacing ❑Yes ❑ No �
-- -----
SOIL COVER
Depth Over �Depth Over '� Depth of Seeded/Sodded Mulched �
Cell Center Cell Edges ; Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑Yes❑ No L�3 03 a I �` / � 6ct �� /
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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 AND SKETCH
SANITARY PERMIT NUMBER _____ I''�.9� ___
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