HomeMy WebLinkAbout002-142-01-0500-SAN-2022-016 /"� """` PRIVATE ONSITE WAS�E TREATMENT county
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�s=—'�='"� INSPECTION REPORT sanitary Permit tvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� r �'b
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 INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS EL�V
Septic �,�,�e ��a Benchmark ,qs 1o6.9s'� �o, d�
Dosing
Aeration Bldg. Sewer 5'cfr ' o �
Holdin 6.38 � csp, �
9 St/Ht Inlet
TANK SETBACK INFORMATION St I Ht Outlet .�,$ ' ��,�7 '
TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet
AIRINTAKE
Septic + � -{�' +s� �-5- � NA Dt Bottom
D�sing NA Installation
Contour
Aeration NA Header/Man. 7.a ` �j q,y5�
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM sk�• � �.o � `�g46-�
TDH Lift Friction Loss Sys Head TDH Ft � �•( ' Rg.$,S'
Forcemain L Dia Dist.To Well � $.� ' q�,7 �
DISPERSAL CELL INFO M TION
DIMENSIONS �N ,3` �4��f yy` yY' #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate `�,�I
P/L Bldg Well ❑ IGP � Chamber �v��'
INFORMATION Waters ❑ EZFIow Model Number:
❑ AG
CELL TO �7 p f(cv �� ❑ Mound o Other QY f
— - -- - --- - ------- ----
DISTRIBUTION SYSTEM x Pressure systems Only
-- ---- — ---
Header/Manifoltl 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/Sodded Mulched
Cell Center �ell Edges �Topsoit __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?�Yes ❑ No Qa p� 02 Y [__��� -- ---J �� I-� �
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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 ANO SKETCH
SANITAAY PEAMIT Nl1M8ER: .?.z - �(�
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