HomeMy WebLinkAbout024-641-22-1406-SAN-2023-076 y,,
� "``,' ,,♦,, pRIVATE ONSITE WASICE TREATMENT co�nty
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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 putposes[Privacy l.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
Y`c��e.ln��i�o„y (a���2 I��t�d� ��R.
Insp BM Elev: BM Description: Parcei Tax No:
�,���� Nq\�, � �c/ � O�-`{ �{7�( '��".( — �'f��v
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �y� � J (vc.,� ��,,, 3�� Benchmark (oo.o �
Dosing
Aeration Bldg. Sewer
Holding St I Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet ,��
TANK TO P/L WELL BLDG VENT TO ROAD DHrrtet�� 5 T .t,N
AIR INTAKE 9�,�7
Septic ���� �} � � NA �• 51' �-cT' `?�, �, �
Dosing NA Installation
Contour
Aeration NA Header/Man. qY, �3�
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative �3.b �
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 W � � H y #of Cell Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate
SETBACK P/L Bldg Well OHWM of Nav � IGP ae� Chamber ^ I �
INFORMATION Waters � AG ❑ EZFIow Model Number:
CEIL TO � r}-�.� .}-� �✓ ❑ Mound o Other !1 �
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— -- — -- -_ ___ _ __ _ _
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipe�
Length Dia l Length Dia Spac � Spacing ❑Yes ❑ No �
_--_ --- --- �-
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SOIL COVER
( Depth Over �epth Over Depth of Seeded I Sodded Mulched �
� Celi Center Cell Etlges i Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision re uired?�Yes � No 'v 3 � y I �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3101)
AOOITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA:__.� �'a7�P
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