HomeMy WebLinkAbout032-539-05-3202-SAN-2021-358 �"�t"'"T"���; PRIVATE ONSITE WASTE TREATMENT county
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'�='^�����'�' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � — 3��
Pe�onal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(in)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Descri n: Parcel Tax No:
(D�.o� M�s•2Qe. o�'c- •,� ,� a 3�-53`t -o.S .320�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS .ELEV
Septic Q • � ��� Benchmark 3,� � �3, ( � '
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Dosing 7y't� �
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St I Ht Outlet
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom ��,p' �S r
Dosing NA Installation
Contour
Aeration NA Header/Man. ,Y � ��;�'
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Surface e �l.b � `�1-� �
Manufacturer Demand Final Grade
Model Number ..� GPM H• 1P I_. �,O � (Q� � �
TDH �j Lift Friction Loss Sys Head TDH Ft
Forcemain L.���' Dia �� Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W (� � �S � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � IGP ❑ Chamber
a AG ,� EZFIow Mode�Number:
CELL TO ���` .}1 pa � N 5� Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Man fold u Distribution P� e s � �� X Hole Size X Hole ��
9 � ��� �p ( ) � / , 3� Observation Pipes
Len th Dia � Length� Dia �- Spac� _ 513�'' Spacing �Yes ❑ No
SOIL COVER
— — -- --- —
Depth Over ,� Depth Over �, ' Depth of � „ Seeded I Sodded Mulched
Cell Center �o�- Cell Edges �a Topsoil �Yes ❑ No �'Yes ❑ No �
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision required?0 Yes 0 No I��d � �� / - � (/��j n �
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Use other side for additional information Date POWTS Inspector's Signature J Certification Number
SBD-6710(R.3/01)
�� AOOITIONAL COMMENTS AND SKETCH
`�� SANITARY PERMIT NUMBEA�____21 �-_��$___
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