HomeMy WebLinkAbout020-639-11-5301-SAN-2021-314 ���=�' ``` PRIVATE ONSITE WASTE TREATMENT county
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"fZ'-�'��'�=� INSPECTION REPORT sanitary Permit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a� „ �j��
Pe�sonal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village �Town of: State Pian Transaction ID#:
C-�,�:s� �- �.�ah ��;��A P�r�-daatoa2�8- �
Insp BM Elev: BM Description: Parcel Tax No:
(oo.a ` na, � d-r��o�, ib���all. 0�o-63q-- l1 -�'3a I
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic sk _ Benchmark ��,p�
Dosing .- �,,h� p
Aeration Bldg. Sewer �
Holding St/Ht Inlet ��
TANK SETBACK INFORMATION St!Ht Outlet ,�
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic rYo� '�oo' fig � NA Dt Bottom �(.3z�
Dosing � �• � ., NA Instaliation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe 'j � �
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PUMP 1 SIPHON INFORMATION Surface e �l'7,a �
Manufacturer �r. Demand Final Grade
Model Number �� GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W ,b7� � ?� � #of Cells i Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv � Aggregate
P I L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO �'�o` ,�- � � .f- �p� o Mound o Other
---- —_ —_------- ----
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s � « X Hole Size,, X Hole i Observation Pipes
Length ��ia--�ength��,3� Dia 2 Spac � e.l _ Spacing �•93 �Yes ❑ No __
SOIL COVER
------- ----- —
Depth Over 1 G Depth Over �� Depth of ,r Seeded I Sodded Mulched
Cell Center \� 1 Cell Edges �� Topsoil ��_ p�l Yes ❑ No �Yes ❑ Nu
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?�Yes❑ No -pa oq �3 , _ � �j�S'� t�
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NIJMBEA: � I r 3�_
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