HomeMy WebLinkAbout030-737-03-5312-SAN-2021-366 �� ``r<� PRIVATE ONSITE WASTE TREATMENT county
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k��'°�'�/ INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a. 1 _ 36�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
�o,d ' � 6�' �kc. ��.�� �o� �30_-��3?— 63-5�3� �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �, � �o�,� � m,o '
Dosing
Aeration Bldg. Sewer � "i7,'� '
Holding (�/ �,�CJa '2$� St/Ht Inlet �,$ � �7, 3'
TANK SETBACK INFORMATION St I Ht Outlet �o � q7, � '
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom �•�2. � `�� ,$$�
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding } o` ` � � L�,�' � Dist. Pipe
PUMP 151PHON 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 L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters o GP � Chamber Motlel Number:
❑ EZFIow
CELL TO o Mound � Other
___— --__ -- -- ---- — --- --__
DISTRIBUTION SYSTEM X Pressure Systems Only
- --
Header/Manifold Distribution Pipe(s) Xi Hole Size X Hole Observation Pipes
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Length Dia Length Dia Spac S acin ❑Yes ❑ No
- --- -- — —-- ----�_ P 9
SOIL COVER � �
— - - -- --__ _ -
Depth Over Depth Over I Depth of � Seeded/Sodded Mulchetl �
Cell Center I Cell Edges I Topsoil ❑Yes ❑ No ❑Yes ❑ No
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COMMENTS: (Inclutle code discrepancies, persons present, etc.)
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Plan revision required?❑ Yes❑ No � , �Y a3 � _ ^ � _ ) �j�l��� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL C�MMENTS ANO SKETCH
SANITAAY PEAMIT NlJMBER: a I-.3��__
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