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4 <br /> Safety n DepartmentofCommerce PRIVATE SEWAGE SYSTEM Count <br /> Safety and Buildings Division <br /> INSPECTION REPORTL�{� <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: <br /> Personal information you provice may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. 0 , <br /> Per Holder's Name: ❑ Cit ❑ Village Wown of: State Plan ID No.: <br /> �+C <br /> CST SM Elev.. Insp.BM Elev.: BM Description: Parcel Ta No.: <br /> TANK INFORMATION ELEVATVON DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic Benchmark 1,, 75- <br /> Dosing 75'Dosing <br /> Aeration Bldg.Sewer <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet It— <br /> Septic > y(^ 5 NA Dt Bottom �J <br /> Dosing NA Header/Man. �/ 2 <br /> Aeration NA Dist. Pipe 537 3� <br /> Holding Bot.System 5 6 <br /> PUMP/SIPHON INFORMATION Final Grade ,g� <br /> Manufacturer Demand <br /> Mode[ Number GPM <br /> TDH I Lift Friction System TDH Ft <br /> Lossead <br /> Forcemain Length Dia. Fi Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Lengti6elNo.Of Tren es PIT No Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONSDIMENSIONS <br /> SYSTEMTO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK <br /> INFORMATION Type O > �i / i / CHAMBER Model Number: <br /> System: OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header//M/ Id Distribution Pi ) ✓ Dt Hole Size x Hole Spacing Vent To Air Intake <br /> ` --,,-Ix 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 07N 0 <br /> COMM NTS (Include code discrepancies, persons present,etc.) 14A <br /> �P/YdNi� �OSI�I <br /> SaWer ns� <br /> Plan revision required? ❑ Yes 1!"0 <br /> Use other side for additional information. 171211 Oil ii <br /> SBD-6710(R.3/97) Date Inspector's Signature Cert No <br />