HomeMy WebLinkAbout028-274-00-0800-SAN-2023-069 ` ""`E` PRIVATE ONSITE WASTE TREATMENT County
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`"' ' "" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 23 .� ��
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#:
�C�J�ha-e.. C'��f�a�+� -L^�'�tSc..� 7{i��.,aKs-� r�
Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark (��a �
Dosing
Aeration Bldg. Sewer
Holding W�� �.pcx� St/Ht Inlet �,S' �
TANK SETBACK INFORMATION St I Ht outlet
TANK TO P/L WELL BLDG VENT TO ROAD Ot Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding t�o f1-S � fi� ��2. j Dist. Pipe
PUMP 151PHON 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 �N L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bitlg Well Waters °� GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound � Other
-- - - ---- ----_ _ ------- ----_-
DISTRIBUTION SYSTEM X Pressure Systems Only
------- -- - - —
Header/Manifoltl Distribution Pipe(s) X Hole Size X Hole Observation Pipes '
Length Dia Length Dia Spac I Spacing ❑Yes ❑ No ��
-- — - �_— -- --- --- �
SOIL COVER _ _
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Depth Over �pth Over � Depth of � Seeded I Sodded Mulched �
Cell Center Cell Edges i Topsoil _ _ _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required7�Yes ❑ No �3 0� �t� I /���—
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PEAMIT NUMBER ____�1�-Q�o�__
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