HomeMy WebLinkAbout008-222-00-1400-SAN-2021-420 ,°`.`-'RT'"E`:` PRIVATE ONSITE WASTE TREATMENT county
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�E'-�"�^-�''' INSPECTION REPORT sanitary Permit rvo:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 „_ L(2�
Personal infonnaCion you provide may be used for secondary purposes[Privacy Law,s. 15.04(])(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:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION �S HI FS ELEV
Septic � �,p Benchmark p,� ` �pp,�` po,o�
Dosing
Aeration Bldg. Sewer 3.6S ' G �
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Holding St/Ht Inlet 6.f � � , '
TANK SETBACK INFORMATION St I Nt Outlet ,(,.�� ` � ,q�`
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .��' }-�� �` +s� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. 7."� � �(a.S�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM 5`r5 � ��• � �a.a�
TDH Lift Friction Loss Sys Head TDH Ft � �.7 � �r�a-�
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS �N 3 L (�Y (,, #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �S ,
INFORMATION P I L Bldg Well Waters a GP (q� Chamber Model Number:
❑ EZFIow
CELL TO •�a..S �F-(o` �-c� _ _kl oo_ ❑ _ Mound o Other ��� -
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) - — � X Hole Size ; X Hole Observation Pipes�
Length Dia Length Dia Spac i ''�� Spacing ❑Yes ❑ No
SOIL COVER
Depth Over Depth Over T Depth of Seeded/Sodded Mulched
Cell Center �ell Edges I Topsoil __ _ ❑Yes ❑ No l ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision required?0 Yes� No
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBEA:_._�.- �O
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