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` us , /// ()& 11-Y- 67cl <br /> Safety h DepartmentofCommerce 1�1PRIVATE SEWAGE SYSTEM Co ty: <br /> Safely and Buildings Division <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryyPrmitNo.: <br /> Personal information you provice may be used for Bary purposes[Privacy Law .15.04(1)(m)]. <br /> Per it Holder's Name El City El Village Town of: State Plan ID No.: <br /> i <br /> C BM Elev.: Insp.BM lev7165a ption: P/o�rcel Tax No.: <br /> S'&_ Zr1,7 U3c,-2 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic 5 Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer '7, 9 <br /> Holding St/Ht Inlet 91(o 3• �� <br /> TANK SETBACK INFORMATION St/Ht Outlet gs <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet JL <br /> Air Intake <br /> Septic 5 �- NA Dt Bottom <br /> Dosing NA Header/Man. ?:� <br /> Aeration NA Dist. Pipe o2- 30 <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade (fib <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH I Lift Friction System TDH Ft t? p �, 3 <br /> oss Fi <br /> Forcemain Length Dia. Dist.To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width I Length / No. f renches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENS1 DIMENSIONS <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer: <br /> SETBACK CHAMBER <br /> INFORMATION Type O Mo el Number: <br /> System:/ .r7 �✓ D OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani old Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake <br /> Length � Dia. Length 3a Dia- � 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 ❑ Yes C] No El Yes E] o <br /> COMMENTS: (Include code discrepancie 4per greset, tc_le �;f <br /> Plan revision required? ❑ Yes EINoyq <br /> Use other side for additional information. � t"I <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert.No <br />