HomeMy WebLinkAbout020-638-03-4409-SAN-2023-126 , '"' `` PRIVATE ONSITE WASTE TREATMENT County
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k�"""�'� �� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ (��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Viilage �Town of: State Plan Transaction ID#:
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Insp BM Elev: B Description: Parcel Tax No:
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TANK INFORMATI N ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �po,a�
Dosing
Aeration Bldg. Sewer � y�,6a '
Holding � �� St/Ht Inlet � t8 r
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding �� (�/ L�S 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 W L #of Celis Type of System Distribution Media Manufacturer'
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
- _ -- - _.-- ---- --- — — -----------
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) -- TX Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac 'I Spacing ❑Yes ❑ No
SOIL COVER
— ----------_ _ __
Depth Over Depth Over Depth of Seeded/Sodded r Mulched�
Cell Center Cell Edges �I Topsoil __ ❑Yes ❑ No � ❑Yes G No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑ Yes❑ No �I���p� �Y '� � � �� ��� �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA:__�-�^ Io�-____
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