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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION <br /> ermit Holder's Na Cit Village Town of County Sanitary Permit No. <br /> tene, she I 39 <br /> State Plan 1D No. Tax Parcel No. Property Address if Available <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. VENT ROAD <br /> TO AIR <br /> 7a INTAKE <br /> SEPTIC >c, 2t a5 <br /> DOSING <br /> AERATION <br /> HOLDING <br /> PUMP/SIPHON INFORMATION <br /> Manufacturer: Model No. Demand in GPM Vert. Lift <br /> FORCE MAIN INFORMATION FRICTION LOSS <br /> Length Diameter Dist. To Well Component Head TDH-As Built TDH- Design <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT-T-r1- COVER MATERIAL No <br /> Cell Width Cell Length Cell Diameter Cell Depth Horizontal Li id Depth No. of Ce s <br /> 6 j a Separation <br /> LEACHING CHAMBER OR UNIT Manufacture 1, Model No. / <br /> SETBACK INFO. Property Line + I Bldg. I Well-T6 7 5� I Lake/Stream <br /> DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifo d Distribution Pipe(s) Hole size Hole Spacing Obsv. Tubes <br /> (� <br /> Inst..&No. <br /> Length I Dia. I Length 1701 1 Dia.qI I Spacing I 11157-M <br /> SOIL COVER <br /> Depth over center of Depth over edge of Depth of Topsoil Seceded/Sodded Mulched <br /> cell: cell: S pe-1-cod L <br /> EVIATIONS FROM APPROVED PLAN <br /> DATE OF INST.DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL TO LEGAL COUNSEL: <br /> COMMENTS(Persons present screpancies,etc.) <br /> Zo /ft� (tf�,e-- nhn Zpa�{��r/� p� <br /> (uf,� I a&- <br /> CO PONENTSNOTINSPECTED <br /> �G l &L- cne, a i0spCeCM(Y-L- <br /> Plan Revi L'qn Required ate: Si ture of Inspector: Pert.Numb r <br /> 7 Yes No �-� <br /> Sketch on other side <br />