HomeMy WebLinkAbout026-939-29-2203-SAN-2021-342 ���""?"`��r� pRIVATE ONSITE WASTE TREATMENT county
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��='�='�^�'`� INSPECTION REPORT sanitary Permit tvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �,, �3 �(2
Personal inYormation you provide may be used for seco dary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: „�N- ❑City ❑ Village [�Town of: State Plan Transaction ID#:
S�- t�,� � .R�,��, �„� Sa�� �QI,� --
Insp BM Elev: BM Description: Parcel Tax No:
�oo.o' 13`� ,g,�z t,.� .5�.,�e.,..> 02(,-932-29-22��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,�,� ,� oop Benchmark �,q � �O�.q ' loo.o�
Dosing
Aeration Bldg. Sewer ��,o ' ��,9'
Holding St/Ht Inlet �.dS � q 3+$S�
TANK SETBACK INFORMATION St I Ht Outlet $,a,.G ' q j,6Y'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet .
AIRINTAKE
Septic }��-� N� � �7' �� � NA Dt Bottom
Dosing NA Instailation
Contour
Aeration NA Header/Man. �•YS � `�3 YS�
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM S�►_s.� •�!J � `t'�•YS,
TDH Lift Friction Loss Sys Head TDH Ft s S � 9.SS` 2 3 S�
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � � (�Y� ��(� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �.`� ,
INFORMATION P I L Bidg Well Waters � GP �s. Chamber Model Number:
❑ EZFIow
CELLTO �'(o� �I-(p` o Mound o Other _ — �fi
DISTRIBUTION SYSTEM X Pressure Systems Only
- — — ---
Header I Manifold Distribution Pipe(s) I X Hole Size X Hole Observation Pipes
Length Dia Length Dia ____ Spac L___ _ Spacing ❑Yes ❑ No
SOIL COVER
— — __ ______ -- —__
( Depth Over Depth Over i Depth of — Seeded I Sodded T Mulched
� Cell Center �ell Edges ; Topsoil ❑Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes❑ No I p3$ �-,'Z � __� C�� � � �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3101)
ADOITIONAL C�MMENTS AN� SKETCH
SANITARY PERMIT NUMBEA:___ I''3��
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