HomeMy WebLinkAbout002-940-25-5116-SAN-2023-074 -""'`�'"-"'�'%�� PRIVATE ONSITE WASTE TREATMENT co�nty
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"�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� ^ �� C,/
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#:
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Insp BM Elev: BM Description: Parcei Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w:ef.w- r (�ov Benchmark �o,o�
Dosing �- �o,k�, �oU
Aeration Bldg. Sewer �.�,S '
Holding St/Ht Inlet ��,3 �
TANK SETBACK INFORMATION St I Ht Outlet $ E,,o �
TANK TO P/L WELL BLDG vENT ro ROAD Ot Inlet
AIRINTAKE
Septic -�'S �?e,` fi2S, ,�25� NA Dt Bottom �?,$ '
Dosing ,� c, �.
K NA installation
Contour
Aeration NA Header I Man. ,p�
Holding Dist. Pipe
PUMP 1�IPHON INFORMATION Infiltrative
Surface `�•v,
Manufacturer Demand Final Grade
Model Number �f � GPM
TDH (S Lift Friction Loss Sys Head TDH Ft
Forcemain L �h�gb` Dia ol.� Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L `
(� � #of Cells Type of System Distribution Media ManUfaCture�:
Conv ❑ Aggregate
SETBACK P/L Bldg Well OHWM of Nav o IGP � Chamber � '
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO � � �1-�,Qp � ..}.. � ❑ Mound a Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) 'i X Hole Size X Hole Observation Pipe� j
Length Dia 1Length Dia Spac Spacing ❑Yes ❑ No �
-- — _ - - -- --- -- -- -- __ _ _
SOIL COVER
�Depth Over Depth Over 1 Depth of Seeded/Sadded Mulched
ell Center ( Cell Edges �, Topsoil _ __ f ❑Yes ❑ No � ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required.�Yes ❑ No �0 J� • � ' G� S`�/
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL C�MMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA:________o`�,_'_G7_�__
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