HomeMy WebLinkAbout014-941-12-1201-SAN-2023-124 �"�`-"=�=�'�<,;_ PRIVATE ONSITE WASTE TREATMENT county
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\N�``—�� INSPECTION REPORT Sanitary Permit No:
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Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 —� � � �
Perso�al infonnation you provide may be used for secondary purposes[Privacy Law,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 � i ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w i - tp��o Benchmark vQ o r
Dosing — � 6a�
Aeration Bldg. Sewer —
Holding St/Ht Inlet q p 6S �
TANK SETBACK INFORMATION St I Ht outlet Qo. 3 7
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic a; �}Z � �'�� a—�'� � NA Dt Bottom �j;�s'
Dosing �� � w Y NA Installation
Contour
Aeration NA Header/Man. �
Holding Dist. Pipe
PUMP 1�IPHON INFORMATION Infiltrative
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Surface �S- S
Manufacturer ��,� Demand Final Grade
Model Number `�g GPM
TDH q Lift Friction Loss Sys Head TDH Ft
Forcemain L '�� � Dia `� Dist.To Well
DISPERSAL CELL INFO M TION
DIMENSIONS W ,3l L (� � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � COnv ❑ Aggregate ���
INFORMATION P I L Bldg Well Waters °� G � Chamber
❑ EZFIow Model Number:
CELL TO ��c� �-� .r-� �/ ❑ Mound � Other
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DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes i
Length Dia Length Dia Spac Spacing 0 Yes ❑No
__---- --
SOIL COVER
— _ ------- - -
De th Over De th Over De th of Seeded I Sodded Mulched
P P P
Cell Center Cell Edges ! Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No D� �g ,� � ` I ��
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITARY PEAMIT Nl1M8EA:� y �02 ____
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