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cv � tUAIL 17 198 /0. 3 p <br /> S92Sin Department of Commerce PRIVATE SEWA E S EMCounty:,,-) r^ <br /> 'SaYety and Buildings Division x./(� <br /> INSPECTION REPORT <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be used for secondary purposes[Privacy Law, .15.04(1)(m)]. 8 � <br /> Permit der's Name: ❑ City ❑ Village Town of: State Plan ID No <br /> CST BM Elev.: illi (lam�Insp.BM Elev. BM Des ipt :(/,X/1 Parcel Tax No.: <br /> ,5k, 76� 6 j,7b - Ll, - a53V-0 &db <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic rY,4, t'+L Benchmark �(J <br /> i <br /> Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet la,cpcl <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet <br /> Air Intake ,,C <br /> Septic �as� �� `��f �l NA Dt Bottom ` , S �5�7 <br /> Dosing5l lgi 7 NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot.System S 100 PUMP/ SIPHON INFORMATION Final Grade , V 80 <br /> Manufacturer V mand rn P Of%F 1(0,ac C3✓•.�® <br /> Model Number W�5 _0GPM �n q,30 /JiI� <br /> TDH Lift Friction ti{D System, TDH t <br /> Forcemain Length gtal Dia. Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width--;, I Length r No.Of T enches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS <br /> DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION ypem . >10, ' /00 OR UNIT Moa Number: <br /> System"- <br /> 1Y- CHAMBER <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold Distribution Pipe(s) 4,rov , - 1 x Hole Size x Hole Spacing Vent To Air Intake <br /> Length Dia Length 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 ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> H10 4)ch <br /> an <br /> Plan revision requiredE] Yes o <br /> Use other side for additional infor ton. a- <br /> SBD-6710(R.&97) Date Inspector's Signature Cert No <br />