HomeMy WebLinkAbout010-277-00-2801-SAN-2021-411 ,
""""`� PRIVATE ONSITE WASTE TREATMENT �ounry
=�� o$ = SYSTEMS Sawyer
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INSPECTION REPORT Sanitary Permit No:
Safery and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � � Y�(
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
`v (ati�. GM�� Sy„.►1Rf_ �a �� �—
Insp BM Elev: BM Description: Parcel Tax No:
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� ilJ-c� � �,� ��,.�� o aI/� O } c7-�?'�--�o -� '80 0
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,�,� �aoo d.. 3 �o Benchmark p,�' �p�,sg' o�,a�
Dosing
Aeration Bldg. Sewer �;7S'' q 4.83�
Holding StlHtlnlet �.�g ' qy,p�
TANK SETBACK INFORMATION st t 2 .Qg ' q�.,��
TANK TO P/L WELL BLDG AR,NT°KE ROAD �►etS��.? .oS' 3•S3�
Septic �hS?� � ' �lb � t(b� NA -�fio-rf'o2 � .lq ' 9 .39�
Dosing NA Installation
Contour
Aeration NA Header/Man. �� �{ � o3r
Holding Dist. Pipe
PUMP I SIPHON INFORMATION Surface e `�'�1 91-°3 r
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CEL� INFORMATI N
DIMENSIONS 1N 3 ' �(�p` F,o` (b 6'p' #of Cells Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate <
SETBACK P�L Bldg Well OHWM of Nav o IGP � Chamber �
INFORMATION Waters c AG ❑ EZFIow Model Number:
CELL TO -�` �_ � o�' �v ❑ Mound o Other QY�
— — ___------- ------ -- —_ _—_---
DISTRIBUTION SYSTEM x Pressure Systems Only
--- PO --- -- X Hole Size � p . g _ p_ 1
Lengthrl Marnfold D'a_ _ �L�en9bution Pi e s Dia Spac Ii� , S a�in ❑ Y satio❑n NiOes i
SOIL COVER
_— __ _ _ _ — —
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges �! Topsoil � ❑Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No � � �� I �al ' , � �i,
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIDNAL COMMENTS AN� SKETCH
SANITAFY PERMIT NUMBEA __ �� _ �f�(
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