HomeMy WebLinkAbout002-940-13-5403-SAN-2023-090 "�'",E` PRIVATE ONSITE WASTE TREATMENT county
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' "`' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2 3_��p
Personal infonnatio�you provide may be used for secondary purposes[Privacy Law,s. I 5.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village 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 �,i,¢.y�- � � Benchmark tO��o'
Dosing .—�,.�,� �?,grb
Aeration Bldg. Sewer 3'
Holding St/Ht Inlet ��.3$�
TANK SETBACK INFORMATION St/Ht Outlet gg.o$ �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic S' (V �/ �.J NA Dt Bottom gs'�c� �
Dosing �, 4 „ W NA Installation
Contour
Aeration NA Header!Man.
Holding Dist. Pipe �5:,28 �
PUMP 1 SIPHON INFORMATION Infiltrative Y.�3�
Su rface ����,
Manufacturer �� Demand Final Grade
Model Number (� GPM
TDH �� Lift Friction Loss Sys Head TDH Ft
Forcemain L ��..5 Dia 2'` Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W �� L 5''3 #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav
�( Conv ❑ Aggregate ���e�
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO S 'f-10 .r-� ❑ Mound � Other �S �
- — — -- — ---- - -- ---- --
DISTRIBUTION SYSTEM �_�, X Pressure Systems Only
— — -- _- --— ----- _--- —, --------
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length _ Dia Length Dia Spac i Spacing ❑Yes ❑ No
---- ———
SOIL COVER
— ---—. — —___ _- —
Depth Over Depth Over j Depth of Seeded/Sodded Mulched
Cell Center Cell Edges j Topsoil T ❑Yes ❑ No �Yes ❑ N��
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?�Yes ❑ No �3 la� � � � � ` � � �� �// �
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Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBEA: �.3^d`�O
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