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` , n PRIVATE ONSITE WASTE TREATMENT SYSTEMS Bunrintt count► <br /> ( POWTS) *&hu: <br /> Department et Cemrneroe INSPECTION REPORT sir (�O;x ' <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION 1 j,(S <br /> Personal information you provide ma be used for secon PrivacyLaw,s.15.04(1Xm) 'I i <br /> Permit Holder's Na e: City Village Town of: State Plan Transaction IDS: <br /> � zer JO l S6 <br /> CST ev: Insp BM Elev. BM Description: Parcel Tax No: <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic Benchmark & /( - 0 <br /> Dosing <br /> Aeration Bldg.Sewer S <br /> e r <br /> Holding St/Ht Inlet <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG V KE ROAD Dt Inlet <br /> Septic -9 r 77. / NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aeration NA Header/Man. <br /> Holding Dist Pipe <br /> PUMP I SIPHON INFORMATION Infiltrative <br /> Surface <br /> Manufacturer Demand Final Grade /p, -a g, <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist.To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width 31 LengthI 3�D( No of cele Type of System Manufacturer. <br /> SETBACKP/L Bldg wen oHwM ofNav COn V, CAMBER CHING EZ Fro <br /> INFORMATION waters Model Number. <br /> CELL TO Sir WM::7 7w Al/fl- 1 003}�— <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 ❑Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded!Sodded Mulched <br /> Cell Center I Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (include code discrepancies,persons present,etc.) <br /> Permit Posted? N /V3 buf 1X we�� � -6� <br /> Schedule 40 Ven s and Observation Pipes.6 N ii1s <br /> Cover Material: <br /> Effluent Filter Manufa urer 'Z7 Model <br /> Components Not Inspected: <br /> Plan revision required?❑Yes No `' �aq <br /> I E�L, <br /> Use other side for additional info ation Date POWTS Inspector's Signature (Cert No <br />