HomeMy WebLinkAbout024-741-02-2411-SAN-2023-129 ` '�' `-� PRIVATE ONSITE WASTE TREATMENT County
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'�-""'�`"' INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 _ ���'
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 1�.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
��O:a� �Q� S�Ga�n� . ��� 07-�-�Y � -oa "���� �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic p Benchmark ��p '
Dosing
Aeration Bldg. Sewer --
Holding St/Ht Inlet `�7.�( r
TANK SETBACK INFORMATION St/Ht Outlet �-7, ( '
TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIR INTAKE
Septic o� {��j` S"` �{-S ' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �E�.��
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �g`�,
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR TION
DIMENSIONS �N 3 L Y #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��� �
INFORMATION P I L Bldg Well Waters a GP � Chamber Model Number:
❑ EZFIow
CELL TO fi-� ��` � � ❑ Mound o Other �Y�
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DISTRIBUTION SYSTEM X Pressure Systems Only
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Header/Manifold Distribution Pipe(s) �X Hole Size X Hole Observation Pipes
Length Dia � Length Dia Spac ! � Spacing ❑Yes ❑ No _�
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SOIL COVER
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Depth Over Depth Over Depth of Seeded/Sodded Mulched
( Celi Center �Cell Edges ` Topsoil ❑Yes ❑ No ❑Yes ❑ No
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COMMENTS: (Include code discrepancies, persons present,etc.)
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Pian revision required?❑Yes❑ No � �� � � ��� �
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Use other side for additional infornnation Date POWTS inspecto s Signature Certification Number
SBD-6710(R.3/01)
AO�ITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER:____�._,�_�_��__,
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