HomeMy WebLinkAbout010-841-35-5314-SAN-2023-112 -"'`'�:>; PRIVATE ONSITE WASTE TREATMENT County
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`''�='°="-" INSPECTION REPORT sanitary Permit tvo:
Safety and Buildings Division
(ATTACH TO PERMIT)
GENERAL INFORMATION eZ. 3 .- �� �
Personal infonnation you provide may be used for secondary purposes[Privacy Iaw,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:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w��- Benchmark �po,o �
Dosing
Aeration Bldg. Sewer _
Holding St/Ht Inlet -7 �
TANK SETBACK INFORMATION St I Ht Outlet 6 r
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic � �� �..b� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 95' � �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative Q�Y� r
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain � Dia Dist. To Well
DISPERSAL CELL INF R AT N
DIMENSIONS W L Yy Yy �(Y� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate �
INFORMATION P/L Bldg Well Waters o IGP a� Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO '1-lL� '1'� ry ❑ Mound o Other �y
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DISTRIBUTION SYSTEM X Pressure Systems Oniy
- _ _---___ - - - _--___ _
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No �
SOIL COVER
__ — -----
De th Over De th Over �De th of Seeded/Sodtled Mulched
P P P
Cell Center Cell Edges I Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required7❑Yes❑ No �,�3 U��4 !I � � I, 6-�'j� 1� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS ANO SKETCN
SANITAAY PERM�T Nl1MBEA: __�_,�._���`
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