HomeMy WebLinkAbout012-739-01-1107-SAN-2021-306 -�;�;'"'`;'^z PRIVATE ONSITE WASTE TREATMENT county
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' �"�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACN TO PERMIT) ?�
GENERAL INFORMATION � � �.X��
Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village C�Town of: State Plan Transaction ID#:
W;��iavy '1- I`1 �e�-�uc�� �ur�� �
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 D,�Y (00•S` � /O O�
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Dosing
Aeration Bldg. Sewer ��,y�s ' '
Holding S��-t,�/ s(...Q St l Ht Inlet 3�IS � rl •3 �
TANK SETBACK INFORMATION St I Ht Outlet ��-' 2,3�� ,� �
TANK TO P/L WELL BLDG AIR NTA�KE ROAD Dt Inlet �• '""
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding a- � -{�s' ��� t�S� ��S' Dist.Pipe
PUMP/SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Modei Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv a Aggregate
INFORMATION P I L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound � Other
— — - -- - —— —__— —
— —----
DISTRIBUTION SYSTEM X Pressure Systems Oniy
Header I Manifold —�istribution Pipe(s) — ', X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac � Spacing ❑Yes ❑ No
SOIL COVER
Depth Over Depth Over TDepth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoit ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision re uired?�Yes ❑ No � � r
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA: �_:��� _
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