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�`1ar ' County <br /> r I ` \ Private Onsite Wastewater Treatment ��r2ef-� <br /> \y 'sPs ,' Systems ( POWTS) Inspection Report <br /> o� x <br /> ` .F, (Attach to Permit) Sanitary Permit No: <br /> Industry Services Division <br /> General Information S -2.3- 112 <br /> Personal information you provide may be used for secondary purposes Privacy Law,s. 15.04(1)(m)] <br /> Permit Holder's Name: 11 City 0 Village 4 Town of: State Plan Transaction ID#: <br /> /k\cLf N e- ( 5eAc.Son <br /> CST BM Elev: lnsp BM Elev: BM Description: Parcel Tax No: <br /> l US. 5(0 Na-i.( in 2.3" NDruoct,,( 41980 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road <br /> Septic ,n f--i l-1-aLkar [000 + Z La I l 3 N/A <br /> Dosing N/A <br /> Aeration N/A <br /> Holding <br /> Pump I Siphon Information Elevation Data <br /> Pump Manufacturer Pump Model Demand STATION BS HI FS ELEV <br /> Filter Manufacturer Filter Model LT 1 1 GPM Benchmark 103.Sto i 0 3•S(v ( pD <br /> TDH Lift Friction Loss Head Total Bldg.Sewer 22 <br /> Tank Inlet Lk • 41 97,!P <br /> Forcemain Length Dia Dist.To Well <br /> Tank Outlet (e•(Q 1 %. 95 <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Width 3 Length #of Cells <br /> 1 30 I Dose Tank Bottom <br /> SETBACK FROM Prop.Line Building Well OHWM Inst.Contour <br /> 5 21 51 +SO Header I Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe <br /> ElPlow Model Number:E.z ( 2�3H Infiltrative Surface • 2 ?(p• 3P <br /> Pretreatment Unit IVA Final Grade 5 • ( g.4lCo <br /> Manufacturer: <br /> Model Number: <br /> Distribution System X Pressure Systems Only <br /> Header I 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 0 Yes 0 No 0 Yes 0 No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> Plan revision required? ❑ Yes I No 07 L I 20L� ����,� �t /�I,,,,/. �► I56 5(Q-7 I <br /> Use other side for additional information. ( l /Lf y�� <br /> Date POWTS Inspector's Signature License Number <br /> SRr1J,71n/R n3/911 <br />