HomeMy WebLinkAbout028-742-22-5507-SAN-2022-022 /i� "''�` PRIVATE ONSITE WASTE TREATMENT county
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'�;s'—°V,'•'' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �-� ,� ���
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: Parcei Tax No:
�vo.a '�Q �'�C D��e-"1-c�� �i� 6� �� oag-�7�1� -a-�-S S'o-7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark ,(�� o�,� ' /ao� e�
Dosing
Aeration Bldg. Sewer t S`a � q'�.(� '
Holding ,,���— C�D St(Ht inlet 6 �6Y � t .96�
TANK SETBACK INFORMATION St I Ht Outlet 6,�3 S'� -�S s�
TANK TO PIL WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man.
Holding �.� � �$ -}-(�� �2S ( Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
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:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P�L Bidg Well Waters a GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
-- - - --- — — ------ - -
DISTRIBUTION SYSTEM X Pressure Systems Only
_—_ ---
Header/Manifold 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 ( Cell Edges �_Topsoil _ __� ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No o l.� �3 ��� � c7R���
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Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA: �� —O��
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