HomeMy WebLinkAbout008-937-09-5109-SAN-2023-092 , ,
'�`'' tr:; PRNATE ONSITE WASTE TREATMENT County
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` ���'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� �- a� a
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
ar�.a� `j� �f`� r��s,.r- �� cc�a$'93? —69—S(o�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark (6J,p�
Dosing
Aeration Bldg. Sewer �t;,( �
Holding w�e�' �p (.P St I Ht Inlet 93.q �
TANK SETBACK INFORMATION St/Ht Outlet q3,-7 '
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA installation
Contour
Aeration NA Header I Man.
Holding kcoo �-SD ��j` 'r'Ktj �.02� Dist. Pipe
PUMP 1 SIPHON 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 � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
- ---_-- - -- — —_ __._ _. _._ — ----- ------ ------ —--__ ___--
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X H7 ole Observation Pipes
Length_ Dia �Length_ Dia Spac I � Spacing ❑Yes ❑ No
-- --_ -- -�-----
SOIL COVER
( Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil _ _�❑Yes ❑ No I ❑Yes ❑ f�o
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑Yes ❑ No ' �
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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 ANO SKETCH
SANITARY PERMIT NUMBEA: ��-��__
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