HomeMy WebLinkAbout026-182-01-1900-SAN-2023-106 ,, �` '"`'r; PRIVATE ONSITE WASTE TREATMENT County
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F ' "' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � ?j-- � d�o
Personal infonnation you provide may be used for secondary purposes[Privacy taw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
�N1�c a-��Sq�, \ �„� .e..�,\. ��� �1�, �
Insp BM Elev: BM Descripti n:� �1.� � ��� �,,r,Q Parcel Tax No:
oc�.�' o�s�-1 ` �� 4°�L. a�- (8� -a � - (`loa
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELFV
Septic • �� 'W�es.�•,� Benchmark �c�.o�
Dosing �,,.., .,.i;eS�- �p c� h�t� f-tT-. � .8Y �
Aeration Bldg. Sewer
Holding St I Ht Inlet
TANK SETBACK INFORMATION St I Ht outlet 7_a'
TANK TO P/L WELL BLDG AiR"iNT°KE ROAD 1� Dt Inlet �./S'
Septic NA Dt Bottom �0. 6��
Dosing � ,}- � � / NA Installation
'� o� �"� �I'�a Contour
Aeration NA Header/Man. ,� �
Holding Dist. Pipe
PUMP 1�IPHON INFORMATION Infltrative
Surface
Manufacturer �q �,,� Demand Final Grade
Modei Number GPM SYS, �F'� ��.�
TDH Lift Friction Loss Sys Head TDH Ft SyS. ��'`� d q,7 '
Forcemain L � (�p' Dia �� Dist.To Well �{,'� �-, 9`{,� '
DISPERSAL CELL INFORM TION
DIMENSIONS W ' � � S' ' #of Cells '7 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters ° AG � Chamber Model Number:
� EZFIow
CELLTO -t-�.�� ��o�� � �--la-p� ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
_ _ - --
� � X Hole Size X Hole Observation Pipes
Lengthr/Marnfold Dia L�engthution Pi e s Dia Spac �_ Spacing 0 Yes ❑ No
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SOIL COVER _
-- I --- - --- — ---
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center � Cell Edges � Topsoil __ �❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.) �
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Plan revision required?�Yes O No �3 p7 o2Y � � I 6��(�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBER __�.�_�U�_ ___
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