HomeMy WebLinkAbout032-540-30-3101-SAN-2021-347 '�""'`'``>; PRIVATE ONSITE WASTE TREATMENT counry
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`-x'-����^``''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � �. '�jc.('7'
Pe�sonal infonnation you provide may be used for secondary pucposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�,Town of: State Plan Transaction ID#:
J�""�h � '•`� � 19 f f r l/v�,n�eS— �
Insp BM Elev: BM Description: Parcel Tax No:
lOo.o ` �a Sc.�-e.•� 1,. e-�S� Si`�12a� �, w�� 03� .���10-30-31a 1
TANK I ORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �p(�p Benchmark —L�.67 � �t9.33� f o o•o�
Dosing
Aeration Bidg. Sewer �;6 7 ' q ?j,(,6'
Holding St/Ht inlet �;q ' 3.Y g'
TANK SETBACK INFORMATION StI HtOutlet 6,17 ' k. � �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet �
AIR INTAKE
Septic �-a5` �Yo' k,� fi,� � NA Dt Bottom •
Dosing NA Instatlation
Contour
Aeration NA Header/Man. �•33 � `t 3,a �
Holding Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative 7�S.r � � o��
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR TION
DIMENSIONS W 3� � O� D � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav 9� Conv ❑ Aggregate
INFORMATION P/L Bltlg Well Waters � IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELLTO _�'��` .}.�o� �-6o N ,q- ❑ Mound o Other —
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) ' X Hole Size 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 Topsoil ❑l'es ❑ No l ❑Yes ❑ No�
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes ❑ No i �3 6$ a � / _ — ! 6c� �( / �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANIT,4RY PERMIT NUMBER: �� � 3 K�7
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