HomeMy WebLinkAbout010-841-15-4207-SAN-2023-065 ''"� :,� PRIVATE ONSITE WASTE TREATMENT co�nty
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� �'_��' � INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 � �p�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 1�.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village (�Town of: State Plan Transaction ID#:
(�.c�\��-�,isc, �1enZ.�(J r �qyu,aC?�1 .—
Insp BM Elev: BM Description: Parcel Tax No:
10� �� � o to - �Y�-- (�'�Y�.0-7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,�,�e�:� t,a�c Benchmark �op,o�
Dosing
Aeration Bldg. Sewer qY �
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Holding St/Ht Inlet � , �
TANK SETBACK INFORMATION St/Ht outlet ,� �
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIRINTAKE
Septic � N �/ NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 93.� �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative t
Surface �2•s
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMAT ON
DIMENSIONS W 3� � (.� (,Y #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate j,� ,
P/L Bidg Well � IGP rp�Chamber �'��"`
INFORMATION Waters � AG ❑ EZFIow Model Number:
❑ Other
CELL TO '�Z S' �/ [✓ ❑ Mound �{�
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- -- � p � � i X Hole S ZeS stems Oniy
DISTRIBUTION SYSTEM _ ___ y_
— _
Header I Manifoltl Distnbution Pi e s X Hole Observation Pipes I
Length Dia Length Dia Spac I I Spacing ❑Yes ❑ Nc �
-- --_.— — -- _
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� No ��p p � �� �� ���
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS�NO SK�f�-I
SANITARY PERMIT NUMBER: �=6_S___
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