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the A-peRmmt of Safety aad Pcofassional Seniea. Pasonal amfamati�pan pia��mag be a�od for seeaadas� }J�
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\�`�""`'"��';`?� 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)J
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM ev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic 5�� � �,� Benchmark �vc.�� ��o ;�
Dosing
Aeration Bldg. Sewer �j(� 3�
Holding St/Ht Inlet �(S.7
TANK SETBACK INFORMATION St I Ht Outlet �j�_yH
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ,� 4/�,�- ��,��` NA Dt Bottom
Dosing NA Instaliation .
Contour .
Aeration NA Header/Man. - �f�.��
Holding Dist. Pipe '
PUMP I SIPHON INFORMATION Surface e �� ��
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 I L Bldg 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 I ', Spacing ❑Yes ❑ No
' --__ _ .....'.___. _ L _- _--�_ ___ _.
SOIL COVER
_— -- —
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center �ell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes� No �i � 7 � �<%���' �-t�-/ l�-�= �� ��
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NlJMBER:�t� -���_
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