HomeMy WebLinkAbout010-941-26-3104-SAN-2021-404 , � "'-""�;; PRIVATE ONSITE WASTE TREATMENT county
i�� � SYSTEMS SaWyer
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��,��1SPs ��.�-� ( POWTS)
����'�'�'��^-';' INSPECTION REPORT sanitary Permit rvo:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � � UO�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] l
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
(Oo.�� �}� �,�„�r}�vQ � �,.� ca�a � o��--qYl_�L� 3�o y
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic r- �060 Benchmark �pp,fl�
Dosing '
Aeration Bldg. Sewer q'7;�7'
Holding St/Ht Inlet Q6,$�r'
TANK SETBACK INFORMATION St I►-�t Out�et q6.5�9'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic � �.�� .�` .}� � NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man.
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative 4Y 3 �
Surface
Manufacturer Demand Final Grade
Model Number GPM ��-(Ww1 � ,6'7�
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/L Bldg Well Waters o �GP ❑ Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO o Mound o Other
-- — -- — --- -----
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pi e s
- --
-------
p ( ) j X Hole Size X Hole Observation Pipes
Length Dia Length Dia _ _ Spac �_ __ Spacing �Yes �No �
SOIL COVER
— — -- --
Depth Over Depth Over Depth of Seeded/Sodded I Mulched �
Cell Center Cell Edges �Topsoil ❑Yes ❑ No
( ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required70 Yes❑ No �3 �� I ] .�I �—y��--- __ i 6��� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADDITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: 2� - ��Y
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