HomeMy WebLinkAbout028-282-00-0100-SAN-2023-072 '��``-��"",�^` PRIVATE ONSITE WASTE TREATMENT county
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°` '°`� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3_ b��
Personal infonnation you provide may be used for secondary purposes[Privacy Iaw,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:
����d � �J�� a �' S�SS� Gr�-�a ���—a'��{�O—0100
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w� '�� Benchmark �U�,,d `
Dosing
Aeration Bldg. Sewer ,
Holding St/Ht Inlet �
TANK SETBACK INFORMATION St/Ht Outiet ��� �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �„ � �-�,S� �� +. � NA Dt Bottom
D�sing NA Installation
Contour
Aeration NA Header/Man. 9 y• Y� �
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
surface 1,3.Ya�
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 3 L 2 (o #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �,
INFORMATION P/L Bldg Well Waters � IGP � Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO �S- � �op ❑ Mound o Other �,7,�
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifold Distribution Pipe(s) - ;X Hole Size X Hole Observation Pipes— j
Length Dia �Length Dia Spac �� Spacing ❑Yes ❑ No �
-- _----
SOIL COVER
__ — _—
De th Over De th Over De th of Seeded/Sodded Mulched
P P P _ _
Cell Center Cell Edges j Topsoil ___ _ ❑Yes ❑ No ❑Yes ❑ �lo
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required7❑Yes ❑ No I p� ���,y �� - � � �g�J�
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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 AN� SKETCH
SANITARY PERMIT NUMBER __ _�-_b��_____
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