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_,anent of Industry, PRIVATE SEWAGE SYSTEM County: <br /> .man Relations INSPECTION REPORT r Ll l h <br /> .o Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> GENERAL INFORMATION <br /> Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No <br /> BIII Lezyrar&__� I nr3k"I <br /> CST BM Elev.: Insp.BM Elev.: B Descriptio / y �D 'f M S 1 Parcel Tax N : <br /> 1 —O✓ —�-700lSf1Ja }{n <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURERL CAPACITY STATION BS 5 <br /> HI FS ELEV. <br /> Septic eke Cmntl�ele_ Benchmark a,4l 4� 6d <br /> Dosing <br /> Aeration Bldg.Sewer - <br /> Holding St/Ht Inlet . 610 �; p <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANKTO P/L WELL BLDG. Vto <br /> enttake ROAD Dt Inlet <br /> Septic 13� NA Dt Bottom -- <br /> Dosing NA Header/Man. �S 63 <br /> Aeration NA Dist. Piper j <br /> Holding Bot.System <br /> PUMP/SIPHON INFORMATION Final Grade <br /> Manufacturer Demand <br /> Model Number GPM osr�' 3, D ,! <br /> TDH Lift Friction System TDH Ft <br /> ead I <br /> Forcemain Length Dia. FI Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length No.Of Trenches PIT No Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS /8� -�7_ c._,L_� DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L I BLDG WELL LAKE/STREAM LEACHING Manufacturer:INFORMATION Type O gD �1� ysa 3 OR UNIT CHAMBER Model Number: <br /> System: OC <br /> DISTRIBUTION SYSTEM <br /> Header/Manifold . if Distribution Pipe(s)� yt s x Hole Size x Hole Spacing Vent To Air Intake <br /> Length 1a&� Dia. `7� Length_2 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 /> 30.3 <br /> sl ' aj Cofer <br /> �� I nay <br /> Plan re s o re re ? Yes �No <br /> Use other side for additional information. 8 6 Cryry <br /> 13 <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert No. <br />