HomeMy WebLinkAbout018-837-12-3101-SAN-2023-314 >��
`"'-"E`�; PRIVATE ONSITE WASTE TREATMENT cou�ty
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'"` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �,3 -3� y
Personal infonnation you provide may be used for secondary purposes[Prrvacy L.aw,s. 1�.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 �?X;,�1,�, S�-w �p�o Benchmark Ic�o .o�
Dosing
Aeration Bidg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet qc�.7 '
TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header!Man. ,� �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative 88��,�
Surface
Manufacturer Demand Final Grade
Model Number �P� �_ fA��,,q. `TO .$�j�
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR TION
DIMENSIONS W � f'� #of Cells Type of System Distribution Media Manufacturer' �
SETBACK OHWM of Nav
� Conv o Aggregate �� �
INFORMATION P/L Bidg Well Waters o GP �C Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other �QL3�
-- -- ---- —
DISTRIBUTION SYSTEM X Pressure Systems Only
__ - -------- — —
Header I Manifoltl Distnbution Pipe(s) I X Hole Size , X Hole Observation Pipes
_
Length Dia Length Dia Spac � Spacing ❑Yes ❑ No
SOIL COVER
__ _ -_ ---
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges Topsoil __ ��Yes ❑ No ❑Yes ❑ Vo
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes 0 No �� � ��
03���',�- � � � - ���� 6 S�
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: _�3__`��",_
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