HomeMy WebLinkAbout028-642-31-2104-SAN-2021-333 /� ' ``` PRIVATE ONSITE WASTE TREATMENT county
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\`1F�'e INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (A T T A C H T O P E R M I T)
GENERAL INFORMATION o�. l — 333
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 �,,;e -- �a oo Benchmark �vp, �
Dosing r�,.„,�o boo
Aeration Bldg. Sewer q�j, Y(� �
Holding St I Ht Inlet q���8�
TANK SETBACK INFORMATION St/Ht Outlet q �,q3'
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic ' ,�/ � ` ,�.� ' NA Dt Bottom �,b3�
Dosing „ c� � �, NA Installation
Contour
Aeration NA Header/Man. q,?,p�
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative
Surface ���� �
Manufacturer C� Demand Final Grade
Model Number Z$2f GPM �� P�• Q3•�3 �
TDHS" Lift Friction Loss Sys Head TDH Ft
Forcemain L �a►�o� Dia �" Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N 3 L c�' � � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��,'
INFORMATION P I L Bldg Well Waters a GP 1� Chamber Model Number:
❑ EZFIow
CELL TO _ }�� ..}.L �- ❑ Mound o Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifoltl Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac � _ Spacing ❑Yes ❑ No �
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SOIL COVER
( Depth Over Depth Over �Depth of — l Seeded/Sodded � Mulched �
� Celi Center Cell Edges Topsoil � ❑Yes ❑ No ❑Yes ❑ �lo
COMMENTS: (Include code tliscrepancies, persons present,etc.)
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Plan revision required?❑ Yes ❑ No �
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Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AO�ITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBER: ��- ��
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