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Libor ndHuDepartmentnofIndustry PRIVATE SEWAGE SYSTEM County <br /> Labor and Human Relations INSPECTION REPORT &4( <br /> GENERAL INFORMATION <br /> Safety and BuiYdings Division <br /> (ATTACH TO PERMIT Sanitary Permit No.: <br /> Permit older's Name: p City Ll Village Town of: State Plan ID NO.: <br /> CST BM lev.: Insp.BM Elev.: BM Description: YH>°r Parcel Tax No.: <br /> /v ;12' Id q?� S�/r� / { <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic j� Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL I BLDG. Ventto ROAD Dt Inlet <br /> Airintake <br /> Septic Jfb 33'1 NA- NA Dt Bottom <br /> Dosing NA Header/Man. (o•7s� , / / <br /> Aeration NA Dist. Pipe 6 7,f <br /> Holding Bot. System 738'L <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Forcemain Length Dia. H Dist Towell <br /> SOIL ABSORPTION SYSTEM <br /> BD/TRENCH Width Length�ty No Onches PIT No.Of Pits Inside Dia. Liquid Depth <br /> D <br /> / DIMEN I N <br /> SETBACK <br /> SYSTEM TO P/L I BLDG I WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION _Typ­e0_T CHAMBER Model Number: <br /> System: D 5 rj�' OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold /r Distribution Pipe(s)� /�� x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia. Length a7 Dia. #_-j Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil p Yes p No p Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> Plan revision required? ❑ Yes No �y� <br /> Use other side for additional inform Uon. 25 /� <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />