HomeMy WebLinkAbout012-640-17-2115-SAN-2021-422 '�""'''°�%; PRIVATE ONSITE WASTE TREATMENT county
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jX;'��B `;:� SYSTEMS Sawyer
'�;,�sPs '='' ( POWTS)
��`"x���»^ �`V INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION p�l — 3 y� L��
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#:
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Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMA ION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,,,�� Benchmark D •a S f�0.2� Ov•a �
Dosing
Aeration Bldg. Sewer y 6 r Q ,
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Holding St/Ht Inlet � �S', s�
TANK SETBACK INFORMATION St l Ht Outlet �(.9�. ' q�.3 '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Iniet '
AIR INTAKE
Septic fi� �-�� ' �-b � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. —]•b 1 `�3- S�
Holding Dist. Pipe
PUMPISIPHONINFORMATION Infiltrative 8.�� ��,2S�
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 � � � #of Cells Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate
SETBACK P I L Bldg Well OHWM of Nav o �GP � Chamber � � �
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELLTO -FS'` fi�_ t(,p 'F�� ❑ Mound o Other (�,�,�
DISTRIBUTtON SYSTEM x Pressure systems Only
Header/Manifold �Distribution Pipe(s) --- � X Hole Size X Hole Observation Pipes�
Length Dia Length Dia Spac T _ _ __ Spacing ❑Yes ❑ N�
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 required?�Yes O No �p3 og a I c ;
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: ___�(r��{��Y��
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