HomeMy WebLinkAbout008-938-34-5203-SAN-2023-089 „%�`'"T” � PRIVATE ONSITE WASTE TREATMENT County
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F�'"` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a� ^ 6��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village l�Town of: State Plan Transaction ID#:
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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 �,t�.�/ - ��� Benchmark ��,,o '
Dosing ^ �o,,,,�o »
Aeration Bldg. Sewer 3 g`
Holtling St I Ht Inlet qa,6 '
TANK SETBACK INFORMATION St/Ht outlet q� � '
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIRINTAKE
Septic y ,F-�s` S'` ks� NA Dt Bottom gg, � �
Dosing <<
�� �, �. NA Installation
Contour
Aeration NA Head�r7�. (q�}; � `�9,53'
Hoidin9 -�-�� 1,�'� �2 ��,�.S-'
PUMP 151PHON INFORMATION � �,,� 3 q�,�,�
Manufacturer Demand Final Grade
Model Number GPM 5`h � 4g•( �
TDH Lift Friction Loss Sys Head TDH Ft Sys 2 �t�.$ �
Forcemain L ��.,s` Dia �.'� Dist.To Well S S� ��S r
DISPERSAL CELL INFORM TION
DIMENSIONS �N � � 3'j #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
P/L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG ❑ EZFIow Mode umber:
CELL TO 4�$' �.3 !oc ❑ Mound 61 Other
- --- - - — _ —�- --_ _ _ __ -—--
__ _----- _ --
DISTRIBUTION SYSTEM X Pressure Systems Only
_ __ ___---- —
Header/Manifold Distribution Pipe(s) ' X Hole Size X Hole Observation Pipes
Length Dia _ Length Dia Spac Spacing ❑Yes ❑ No
— -- ---- - -
SOIL COVER
— - - —
Depth Over Depth Over � Depth of Seeded I Sotlded Mulched
Cell Center �ell Edges Topsoil � ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision required?0 Yes 0 No ��3!� �� `j ���(�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN SKET
SANITARY PERMIT NLIMBER ___ ��'�$_____�/ � C��c�
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