HomeMy WebLinkAbout012-284-00-1100-SAN-2021-357 � '""'`' ` PRIVATE ONSITE WASTE TREATMENT county
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' ��'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 � �� —�
Personal infonnation you provide may be used for secondary pu�poses[Privacy Law,;. 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 INFOR ATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS �LEV
Septic Benchmark S,I g� 03.14� (0�:o�
Dosing
�m � ,,,,,;�.�-- ��po�p Bldg. Sewer �-
Holding ,,:��- O,�a SkU�+�at G, yN 7•3S� q 5�g3�
TANK SETBACK INFORMATION s�srrtt�t G, o�-� -?,`� ' ��^,7$'
TANK TO P/L WELL BLDG A RNNTA�KE ROAD t3�►ft+et }-t �N '�.S � `�'S 68'
Septic NA DT'�6tt�m � ��'j' '�,?S'� �!�;�(3
Dosing NA Instaliation
Contour
�'U .'� "��� ��5� ��S� � ��-S� Header/Man.
Holding . �' �{S'p� fi,.�` �- ' L�S' Dist. Pipe
PUMP I 51PHON INFORMATION Infiltrative
Surface
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 W � #of Cells Type of System Disiribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
-— —___ ------ - — —
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distnbution Pipe(s) I X Hole Size X Ho el 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_ ❑Y'es ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No ,I p 3 , �d �� ' —J�� /�/��� � 6cf�l� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIDNAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBEA: _ a� - 3S�
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