HomeMy WebLinkAbout014-268-00-3500-SAN-2021-381 '"�'''0.";`�%, PRIVATE ONSITE WASTE TREATMENT County
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�'^�+'�^�' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� � 3�I
Personal infonnation you provide may be used for secondaty purposes[Privacy Law,s. 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 INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �e � �p Benchmark Q,S' �vo,s` foc�.o �
Dosing
Aeration Bldg. Sewer �,� � g,s
Holding St I Ht Inlet •3S"� 9 Y.(S�
TANK SETBACK INFORMATION St/Ht Outlet 6.,Sg ` " � ,q �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �o� �1 (,p .�..�p� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 7,q�. ` q 2 ��
Holding Dist.Pipe
PUMP/SIPHON INFORMATION Infiltrative
surface `�7�5� � q l ���
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS �N 3� L ?b` p ' #of Cells a Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate
SETBACK P/L Bldg Well OHWM of Nav � �GP ���
INFORMATION Waters � AG EZFIow Model Number:
CELL TO �oc� '�"�O �/ o Mound o Other
- - - - - --- -----
DISTRIBUTION SYSTEM X Pressure.Systems Only
---- —_ _------- — _---
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Header I Manifold Distribution Pipe(sj ' X Hole Size X oH le Observation Pipes
Length Dia Length Dia_ _ _ Spac I _ Spacing ❑Yes �No
SOIL COVER
--- - — --— __ _
Depth Over �Depth Over Depth of Seeded I Sodded l Mulched 1
Cell Center Cell Edges Topsoil ❑Yes ❑ No � ❑Yes ❑ No �
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑ Yes❑ No p IO� I a� � __���- ! ��vb //
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AN� SKETCH
SANITARY PEAMIT NUMBEA:___._�-_� �
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