HomeMy WebLinkAbout002-940-05-1214-SAN-2023-095 ,
"''',f� , PRIVATE ONSITE WASTE TREATMENT co��cy
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'"'' INSPECTION REPORT sanitary Permit tvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a3 �0��'—
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: Parcei Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�,;�.�- ��p-�p Benchmark �oo.o'
Dosing
Aeration Bldg. Sewer Qg.f��
Holding St/Ht Inlet 9�.,2 '
TANK SETBACK INFORMATION St/Ht Outlet q 7,p '
TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIRINTAKE
Septic k�s� k�r �j a-�j ' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. Q o r
Holding Dist. Pipe
PUMP 1�IPHON 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 � �,�( #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��� ,
INFORMATION P/L Bldg Wetl Waters � G �C Chamber Model Number:
❑ EZFIow
CELLTO �(s �-l0 {-�D ❑ Mound o Other Q,2,�
DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifold � Distribution Pipe(s) �i�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 �Cell Edges I Topsoil � ❑Yes ❑ No ❑Yes ❑ I�o
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?O Yes❑ No �Ip3 a(o �,Y � � - � �9�l� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL C�MMENTS ANO SKETCH
SANITARY PE�M�T NUMBER: oZ 3"�`��
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