Laserfiche WebLink
ARr"E'> County <br /> �A\ Private Onsite Wastewater Treatment <br /> Systems ( POWTS) Inspection Report E�(✓le�-�- <br /> „.A (Attach to Permit) Sanittary Permit No: <br /> Industry Services Division 5414 -a-2 -5q <br /> General Information / <br /> Personal information you provide may be used for secondary purposes Privacy Law,s.15.04(1)(m)) C' 3 y t4 7 <br /> Permit Holder's Name: DI City 0 Village I1 own of: State Plan Transaction ID#: <br /> ka �v (1- It O ;5S <br /> CST BOElev: Insp BM Elev: BM Description: Parcel Tax No: <br /> oo 100vat I ,y1 q `' OCk. ' a la-z17 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road <br /> Septic 5 l vJ ipDd I Ito-t 60 20 N/A <br /> Dosing N/A <br /> Aeration N/A <br /> Holding <br /> Pump I Siphon Information Elevation Data <br /> Pump Manufacturer Pump Model Demand STATION BS HI FS ELEV <br /> Filter plan facturer Filter Model GPM Benchmark O. coq 100.04 t p v <br /> TDH Lift Friction Loss Head Total Bldg.Sewer Li.a 8 C1 b <br /> I <br /> Forcemain Length Dia Dist.To Well Tank Inlet �.5 95. <br /> Tank Outlet 1 L1.-7,2 q5. q� <br /> Dispersal Cell Information Dose Tank Inlet � <br /> DIMENSIONS Width- Length #of Cells _ <br /> K Dose Tank Bottom <br /> SETBACK FROM Prgp.Lille By�ild5g WWII OH Inst.Contour <br /> D <br /> Header/Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe d <br /> Q y` LI Model Number: Infiltrative Surface 6.7 6.i ' 13.9 q 9.38f <br /> 1 <br /> Pretreatment Unit Final Grade <br /> Manufacturer: <br /> Model Number: <br /> Distribution System X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing _ 0 Yes 0 No <br /> Soil Cover (\,Pyle& --I-;fru oc :it5Oec'v/1 <br /> Depth Over Depth Over I Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Edges Topsoil 0 Yes 0 No 9 Yes 0 No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> ',154-c,114 e.( ylco(1 <br /> Plan revision required? 0 Yes tErNo 5 ; cp� Emprotimi 15 77Use other side for additional information. IAA. <br /> Date POWTS Is�tor's Signature License Number <br /> SBD-6710(R.03/21) <br />