HomeMy WebLinkAbout032-538-04-4113-SAN-2023-093 "''` `�;; PRIVATE ONSITE WASTE TREATMENT County
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'�'�'� INSPECTION REPORT sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� �O�(3
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Viilage I�Town of: State Plan Transaction ID#:
w1 l G�ce.` �- `T c��5�c� (n/1 t��s`� t���.� `—'
Insp BM Elev: BM Description: Parcel Tax No:
(oo.o' `�g 6� �t.T, ��a�r 1�� a3? -�'�a-ay-Y/�3
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark nd o r
Dosing
Aeration Bldg. Sewer �'�o'
g �{ 3�c�o0 St/Ht Inlet � 6.Y '
Holdin �,,
TANK SETBACK INFORMATION St/Ht Outlet 46,� �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header 1 Man.
Holding �.,�o /J l�. .�-(,�,� �,2 Dist. Pipe
PUMP/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 �N L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv o Aggregate
INFORMATION P/L Bldg Weli Waters � AG ❑ Chamber Modei Number:
❑ EZFIow
CELL TO ❑ Mound o Other
---— -- — -- - — ___.—--- ——--
DISTRIBUTION SYSTEM X Pressure Systems Only
— — --- -
Header/Manifoltl Distribution Pipe(s) '�X Hole Size X Hole Observation PipeS
Length __ Dia _ILength_ _ Dia _ Spac �� _ __, Spacing 0 Yes ❑ No
SOIL COVER
— --- — __— —
Depth Over Depth Over �Depth of Seeded/Sodded Mulched
Ceil Center � Cell Edges I Topsoil _ _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑Yes ❑ No I p3 I 6S— ��c�l � ` � ��'��,(�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER oZ3 ^' Q��
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