HomeMy WebLinkAbout028-782-00-0900-SAN-2023-110 �'�`''"'-"E��;,; PRIVATE ONSITE WASTE TREATMENT county
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F "'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ��^,11�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Q�Town of: State Plan Transaction ID#:
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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 Benchmark (o p•d�
Dosing
Aeration Bldg. Sewer �j7,�,� `
Holding w��f ��(�(O St/Ht Inlet q7,o 6
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding •F�.,` fi,� ` �o` �F-tp' L�2S� Dist. Pipe
PUMP 151PHON 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
INFORMATION P/L Bidg Well Waters � IGP ❑ Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO ❑ Mound o Other
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I TRIBUTION SYSTEM _ _ X Pressure Systems Only
Header/Manifold Distribution Pipe(s) I X Hole Size X Hole Observation Pipes
Length Dia __� Length Dia _ Spac __ j __ Spacing ❑Yes ❑ No�
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Ed es Topsoil _ � ❑Yes ❑ No � ❑Yes ❑ No ]
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes 0 No ,.�2 j o--� �a�i � � , � � ��� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITI�NAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA:�—I I.�_
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