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Safety sil pe ldingsnto(Commerce PRIVATE SEWAGE SYSTEM County <br /> Safety and Buildings Division INSPECTION REPORT 111 <br /> GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No: <br /> Personal information you provice may be used for secondary purposes[Privacyaw .15.04(1)(m)]. XZ <br /> Permit Holder's Name: ❑ c ty ❑ Village own of: State Plan ID No.: ^ <br /> CST BM E ev.: Insp-BM Elev.: BM escr ptio Parcel Tax No.: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic UJ CnZ4e;6� Benchmark ® /OX 0 <br /> Dosing <br /> Aeration Bldg.Sewer q <br /> Holding St/Ht Inlet 5,a3 RY 9 <br /> TANK SETBACK INFORMATION St/Ht outlet <br /> TANKTO P/L WELL BLDG. Ventto <br /> Air Intake ROAD Dt Inlet 1✓ <br /> Septic ->3o `J�D IIN NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe__rS ! �• �3 <br /> Holding I I Bot.System MV 97v2-t) <br /> PUMP/SIPHON INFORMATION Final Grade 61 <br /> Manufacturer Demand <br /> Model Number GPM /o oh5 SIU �'/ 10—. <br /> 0;?• JO <br /> TDH Lift <br /> Friction System Tead DH Ft <br /> Forcemain Length Dia. H Dist.To Well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length / 0.Of Trenchgs PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIMENSIONS6 'L/ DIMENSIONS <br /> SETBACK <br /> SYSTEM TO P/L 1. BLDG WELL LAKE/STREAM LEACHING Manu acturer: <br /> INFORMATION Type` COe� CHAMBER Model Number: <br /> ,j <br /> System: a , }5D IVA-- OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Manifo d . , U Distribution Pipe(s) �y ---, —,71—xHole Size x Hole Spacing Vent To Air Intake <br /> Length \/I_J Dia _/JL' Length 3 Dia. 7 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 <br /> ❑ No ❑ Yes ❑ No <br /> COMMENTS: ,(include code d' crr panties,persons present,etc.) /llefr C4;1 <br /> L/. <br /> e/,"I+reo S� lejqle A <br /> M5�J <br /> Plan revision required? ❑ Yes -GL'No246 <br /> Use other side for additional inforngtion. ffAm r"yw -A [ I I I <br /> SBD•6710(R.3/97) Date Inspector's Signature Cert No <br />