HomeMy WebLinkAbout014-268-00-4300-SAN-2021-339 '�F''"-"'��>; PRIVATE ONSITE WASTE TREATMENT cou�ty
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INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION pZ� � 33�
Personal inYonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village fd1 Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
�0(�.CS� I�fa�` i�n Nl 2 b�� �G O(�{ �-- ��ig^� � -130U
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,,�,Q�- Ooo Benchmark �, � 0',17� I oo.o�
Dosing -
Aeration Bldg. Sewer }3.3 � g,_g� '
Holding St I Ht Inlet 6,��"� �(S'.q`�'
TANK SETBACK INFORMATION St I Ht Outlet 6, S ` �S,.G� �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic {-�� � ±2a t�' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ��p � � S,1��
Holding Dist.Pipe
PUMP 151PHON INFORMATION Surface e , � �
1 4 �,2
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N L o' o #of Cells � Type of System Disiribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG y� EZFIow
CELL TO .(�- � o Mound o Other
— — Sv �S N_ � N�
------____— — ---
DISTRIBUTION SYSTEM X Pressure Systems Only
— -------_. ___T T
Header/Manifold Distribution Pipe(s) X Hole Size i X Hole Observation Pipes
Length Dia Length Dia_ Spac � _ � Spacing ❑Yes ❑ No �
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges I Topsoil__ ❑Yes ❑ No ��Yes ❑ No 1
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑ Yes❑ No i�3 i o$ I �� I� --L� / � �� �(/
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBEfl: �-� — 33_�_
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