HomeMy WebLinkAbout012-640-09-3109-SAN-2021-351 %�"`'""'`"`^��.,� PRIVATE ONSITE WASTE TREATMENT co�nty
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�''�=��'�'��,' INSPECTION REPORT sanitary Perrnit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a f .� ���
Personal infonnation you provide may be used for secondary pucposes[Privacy Law,s. 1�.04(1)(�n)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
(oo.p' Na�� �c-`�o�o►., Y �c, an �E.g�2.e�t-l�-",��e Ot2 - 6�0- vq- 31o�1
TANK INFORMATION `�I`�--�LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�„�� fl Benchmark ,�,�� (O�,a` (Ov.� �
Dosing
Aeration Bidg. Sewer �,o$` q'T,q��
Holding St/Ht Inlet �(.96� �i'],OY �
TANK SETBACK INFORMATION St I Ht Outlet S-, 2T-' � ,-� �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet .
AIR INTAKE
Septic po` � �1/ �/ � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �, o' `�S;O�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Surf cte e ��v � 1 K���
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS �N 3� L (,�y 6 #of Cells Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate �( ,
SETBACK P I L Bldg Well OHWM of Nav � IGP !� Chamber
INFORMATION Waters o AG ❑ EZFIow Model Number:
CELL TO �ob� hJ _ N �__ o Mound ❑ Other - - �y f
DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifold Distribution Pipe(s) X Hole Size X o eIH Observation Pipes
Length Dia Length Dia Spac _ � Spacing ❑Yes ❑No
SOIL COVER
---- -- - - --- — - -
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil __ ❑Yes ❑ No � ❑Yes ❑ No 1
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No Ip3 i v$ �� � _� / JI �c��� � �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: �-� '" 3S�
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