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;Dor , County <br /> t �` Private Onsite Wastewater Treatment <br /> Systems POWTS) Inspection Report l�vrrre44- <br /> (Attach to Permit) Sanitary Permit No: <br /> industry Services Division 5A I/_a'),.►a/y <br /> General Information cl���v <br /> Personal informationyou provide may be used for secondary purposes f Privacy Law,s.15.04(1)(mf] <br /> Permit Holder's Name: U City Village ErTown of: State Plan Transaction ID#: <br /> kc4h C S fer + ?CV1i4 Johr1 Soft )rJe la tie <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> l CC Toe lh lyd a3-7g-7 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake R• oad <br /> Septic _WI cSc,r 3C007 (o,- i P.5 + 5 N/A <br /> Dosing _ N/A <br /> Aeration N/A <br /> Holding <br /> Pump/Siphon Information Elevation Data <br /> Pump Manufacturer Pump Model Demand STATION BS HI FS ELEV <br /> Filter Manufacturer Filter Model GPM Benchmark 2.OS j 02,0s <br /> TDH Lift Friction Loss Head Total Bldg.Sewer L, , $p q 7 <br /> 2-5 <br /> Tank Inlet (�.I{ <br /> Forcemain Length Dia Dist.To Well q ��IQ 21Tank Outlet 6 90.77 <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Width Length #of Cells Dose Tank Bottom <br /> SETBACK FROM Prop.Line Building Well OHWM Inst.Contour <br /> Type of Cell Manufacturer: Header/Manifold <br /> Distribution Pipe <br /> Model Number: Infiltrative Surface <br /> Pretreatment Unit Final Grade <br /> Manufacturer: <br /> Model Number: <br /> )istribution 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 <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No 0 Yes ❑ No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> 1✓I5A 14-Ied be- /I kov.se t ✓1 k <br /> 4 <br /> Plan revision required? 0 Yes 0 No 11 0 P12 PlAfgrilvMA' <br /> 1 5.77PGUse other side for additional information. I d' J <br /> Date POWTS .oector's Signature License Number <br /> SBD-6710(R.03/21) <br />