HomeMy WebLinkAbout008-134-00-1500-SAN-2023-096 ""''"E' PRIVATE ONSITE WASTE TREATMENT county
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"`F' ""' INSPECTION REPORT Sanitary Permit No:
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Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 _ ���
Personal infonnation you provide may be used Por secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village Town of: State Pian Transaction ID#:
W���taw� k�w�ic.a l��c�� �t. � �,.ra ^-
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 ti Z� Benchmark �OO,o �
Dosing
Aeration Bldg. Sewer -
Holding St I Ht Inlet �^9 �
TANK SETBACK INFORMATION St/Ht outiet q�7�
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic }S'` -��-p� I I {-�� � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding 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 �N L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
P I L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO ❑ Mound � Other
_ -- — -----___---- _
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) X Hole Size II X Hole Observation Pipe�
Length _ Dia _ �Length Dia Spac Spacmg ❑Yes ❑ No
SOtL COVER
- — — — -
_
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required7❑Yes❑ No ,O3 � y'� ��_ ��i ���� �
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Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKE,TCH
SANITAAY PERMIT NUMBEA'____��-D�(�___
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