HomeMy WebLinkAbout010-145-00-3101-SAN-2021-319 '°��="``''��� PRIVATE ONSITE WASTE TREATMENT county
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R�s"�'"''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a 1 - ���
Peisonal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village L�,Town of: State Plan Transaction ID#:
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Insp BM Ele : BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic N„��-- �� Benchmark � p � � ,�� �o�,p�
Dosing
Aeration Bldg. Sewer (�,��, � �p � '
Holding St/Ht Inlet 7 ' O , S�
TANK SETBACK INFORMATION St I Ht Outlet I
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TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIR INTAKE
Septic .Ko' N ,� k'�` �- ' NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. I 1,6 S�� 97�3S�
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �� �� �
Surface �((o.
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR AT ON
DIMENSIONS �N 3` L p b.d� -�� #of Cells 3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
P I L Bidg Well o IGP ❑ Chamber
INFORMATION Waters � AG �EZFIow Motlel Number:
CELL TO -}-S i-(c' rr � ❑ Mound o Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header I Manifoltl Distribution Pipe(s) X Hole Size X Hole Observation Pipe�
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
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SOIL COVER
- - - - — --- — -- -
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil __� ❑Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code tliscrepancies, persons present,etc.)
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P�an revision required?�Yes ❑ No �� �3 2 � �
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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
SANITAAY PERMIT NlJMBEA: 2 J -31 q
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