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ART <br /> $f,2� Private Onsite Wastewater Treatment County <br /> 3 Systems POWTS) Inspection Report <br /> � �e <br /> s, A� (Attach to Permit) Sanitary Permit No: <br /> Industry Services Division <br /> General Information Sq-,cJ -.,ID-Lb- <br /> Personal information you provide may be used for secondary purposal Privacy Law,s.15.04(1)(m)] <br /> Permit Holder's Name: Ul City 0 Village ®Town of: State Plan Transaction ID#: <br /> CST BM Elev: lnsp BM Elev: BM Descriptio : Parcel Tax No: <br /> b 00 ram.: I 1 i\ 12- ` ` P!' 4 79 <br /> Tank Information setback to: _ <br /> TYPE MANUFACTURER CAPACITY Prop.Line Well Building Air Intake Road <br /> Septic , 5 kc.i rex,51-1,5) (00(2 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_flan{fac Filter Model GPM Benchmark 2-'It 1 Ga .? <br /> TDH Lift Friction Loss Head Total Bldg.Sewer <br /> Forcemain Length Dia Dist.To Well Tank Inlet <br /> Tank Outlet 5,75 9 6.Q3 <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Wid L iggi #of Cells 3 <br /> 3 Li 4-} Dose Tank Bottom <br /> SETBACK FROM Prop.Line Building Well OHWM Inst.Contour <br /> _ + t +I P .v +50 <br /> Type of Cell Manufacturer: Header/Manifold <br /> �� Distribution Pipe <br /> `Cy Model Number: Infiltrative Surface <br /> q,6 83 9 3.c� <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_ I Spacing 0 Yes 0 No <br /> Soil Cover GUo4e('h' o-cs ;lisp - '7 <br /> Depth Over Depth Over r 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 ipNo ) / 2� - 1 '7-7 J <br /> Use other side for additional information. 1 Jp P ! / <br /> Date POWTS I spector's Signature License Number <br /> SBD-6710(R.03/21) <br />