HomeMy WebLinkAbout024-741-30-1204-SAN-2021-393 %��'''RT`'f���.; PRIVATE ONSITE WASTE TREATMENT county
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�� ' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2 I �, 3c�3
Personal infonnation you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
'l�A�.o�.ti�` c� �CA�h D�'�-5 �,pu.,,o� �1/�+2 �
Insp BM Elev: BM escription: Parcel Tax No:
1
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � �, (06� Benchmark � (OO.o�
Dosing ` .
Aeration Bldg. Sewer r-1�6.I�S�
Holding St I Ht Inlet �b,ob�
TANK SETBACK INFORMATION St I Ht Outlet a S,-�b'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic +�5� �-�.S'� �` �� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. QS;
Holding Dist. Pipe
PUMP 1 SIPHON 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 °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO o Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifoid Distribution Pipe(s) � X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing �Yes ❑ No
— ---�-------
SOIL COVER _ _
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center Cell Edges Topsoil __ ❑Yes � No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision re,uired?O Yes❑ No 63 ��pS �1 � —���u- ��'��� (�� �� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITI�NAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBER ____��-39� _
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