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�!!SPCc, ia�J Wed. 0/- <br /> POWTS HOLDING TANK INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION <br /> Permit H lder's Name LJ CityV' ge Town of County Sani Permit No. <br /> Q / 1-Vl eAl 840-17et - 1 3 <br /> State Plan ID No. Tax Parcel No. Property Address if Available <br /> 426- -v8 80 <br /> TANK INFORMATION <br /> TYPE MANUFACRER CAPACITY <br /> SETBACKS <br /> Property Line Well Water Service Building Service Road OHWM Swimming Pool <br /> } 070 <br /> DEVIATIONS FROM APPROVED PLAN <br /> DATE OF INST.DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL TO LEGAL COUNSEL: <br /> C MMENTS(Persons pre nt,disc rep ies,etc.) <br /> Oat <br /> �- <br /> COMPONENTS NOT INSPECTED <br /> Plan Revision <br /> ix !1d Signature of Ins9side <br /> Sketch on ot <br /> 13 of 14 <br />