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� 44, <br /> k��b`r ` Private Onsite Wastewater Treatment County <br /> yy rs _ . Systems ( POWTS) Inspection Report B,,,,,,c4 <br /> X.: wa Sanitary Permit No: <br /> '� ,���- (Attach to Permit) /� <br /> Industry Services Division 5 i`ll/- a.a-2 3 g <br /> General Information <br /> Personal information you provide may be used for secondary purposeLf Privacy Law,s.15.04(1)(m)I <br /> Permit Holder's Name: U City 0 Village RtTown of: State Plan Transaction ID#: <br /> JTALC EMI' I ier ()I/,©/1 <br /> CST BM Elev: lnsp BM Elev: BM Description: Parcel Tax No: <br /> 2506i- <br /> Tank Information setback to:TYPE MANUFACTURER CAPACITY Prop. Line Well <br /> Building Air Intake _ Road <br /> Septic 19 i f_Se , 1'2-SC) , - .4 (Vrr _ t S 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 anufacturer Filter Model GPM Benchmark --0.7 IC/3 100 <br /> L,' .4-j,m <br /> TDH Lift Friction Loss Head Total Bldg.Sewer 2. Q / 3 <br /> Forcemain Length Dia Dist.To Well Tank Inlet i 1 1 D 9 ,gl <br /> Tank Outlet 14. 7 9 ,56, <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Width 3 Length #of Cells 3 <br /> Dose Tank Bottom <br /> SETBACK FROM Prrop Line Buildjgg WWII, OHW Nj v, Inst.Contour <br /> Type of Cell Man((uffacturer: IV Header/Manifold <br /> '� (�1 Distribution Pipe <br /> Z dclA2 Model Number: Infiltrative Surface 6.ei�Sa 9�.5, Q3,5,9'j. <br /> Pretreatment Unit Final Grade <br /> Manufacturer: <br /> Model Number: <br /> listribution 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 Nolte me akinpr `o 4Depth Over Depth Overt Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil 0 Yes 0 No 0 Yes 0 No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> Plan revision required? 0 Yes gNo f 1 r .77d 6 <br /> Use other side for additional information. l J <br /> Date POWT pector's Signature License Number <br /> SBD-6710(R.03/21) <br />