HomeMy WebLinkAbout012-279-00-0500-SAN-2021-363 -�'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
Petsonal infonnation you provide may be used for secondacy purposes[Privacy Law,s. 15.04(l)(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 INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,•�,Ss� c�o0 Benchmark �bp,o'
Dosing ��Q ?�-p '~�
Aeration Bldg. Sewer qy;y �
Holding St/Ht Inlet �3��
TANK SETBACK INFORMATION St/Ht Outlet �,2.Q '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet �
AIR INTAKE
Septic k,'�� �-��' �-(o ' t�o' NA DtBottom �6,b r
9 , Instaliation
Dosin }�� ����� �� � NA Contour
Aeration NA Header/Man. 9 Y,� f
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative I � �
Surface 5Y5. 3.7
Manufacturer � � Demand Final Grade
Model Number G�Q S GPM $yS• � �3•��
TDH Lift Friction Loss Sys Head TDH Ft , 3 g0,�"�
Forcemain L Dia Dist.To Well 9 y q�
DISPERSAL CELL INFORM TION
DIMENSIONS W �� � 2$ $� #of Cells 3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav D� Conv ❑ Aggregate �
INFORMATION P/L Bldg Well Waters °� GP � Chamber Model Number:
❑ EZFIow
CELL TO +�ti� -}-(o ao' � ❑ Mound o Other Qc��
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) ' X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac ' , Spacing �]Yes ❑ No I
SOIL COVER
Depth Over Depth Over ! Depth of Seeded/Sodded 1 Mulched
Ceil Center Cell Edges j Topsoil__ T�Yes ❑ No � 13 Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes � No �3 �o� �a 6� �� /
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
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