HomeMy WebLinkAbout008-130-00-1200-SAN-2023-091 ` '"'"`=:; PRIVATE ONSITE WASTE TREATMENT County
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F '=�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3 'O�1
Personal infonnation you provide may be used for secondary puxposes[Privacy Law,s. 15.04(l)(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 �,,,;.e, '7� Benchmark �oo,o'
Dosing
Aeration Bldg. Sewer 4�•� �
Holding St/Ht Inlet S Q.( �
TANK SETBACK INFORMATION St/Ht outlet �,�'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic fito� d'.� � 6 � •t-6 � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. �,�"$ �
Hoiding Dist. Pipe
PUMP I 51PHON INFORMATION Infiltrative � ��
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 3 L i #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P/L Bldg Welt Waters Q G ❑ Chamber Model Number:
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CELL TO �. ` t�,�� �►-SD .}�' ❑ Mound o Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pi e s X Hole Size X Hole Observation Pipes
Length Dia � Length pO Dia Spac I�, I Spacing ❑Yes ❑ No �
SOIL COVER
De th Over De th Over De th of Seeded/Sodded Mulched
P P � P
Ceil Center Cell Etlges Topsoil__ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Pian revision required?O Yes❑ No 11�2 In�a,� ,� C� � ____-------� / � �C � �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS AN� SKETCH
SANiTAAY PERMIT NUMBER ____��-0`��____
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