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%3 a ;3 0 <br /> Labor and <br /> Department of industry, PRIVATE SEWAGE SYSTEM county <br /> Labor and Human Relations INSPECTION REPORT <br /> SafPtyand Buildings Division <br /> GENERAL INFORMATION <br /> (ATTACH TO PERMIT) Sanitary Permit No.: <br /> l5�,�s- <br /> Per t Holder's Na ❑ City ❑ Village Town of: State Plan ID No.: <br /> 1 1,15 r <br /> CJAA <br /> CST BM Elev.: Ins BM Elev.: BM�l D�escription: �/ Parcel Tax No.: <br /> 16 ,,C;, / N47�7i✓ Day7�f�p }- - C - 7 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION B$ HI FS ELEV. <br /> Septic ef�r 1&v-e) Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer o <br /> Holding St/Ht Inlet q6 <br /> TANK SETBACK INFORMATION St/Ht Outlet <br /> TANK TO P/L WELL BLDG. Vent to Au Intake ROAD Dt Inlet <br /> Septic 3 _Ilk NA Dt Bottom <br /> Dosing NA Header/Man. <br /> Aeration NA Dist. Pipe <br /> Holding Bot. System 5 sJF <br /> PUMP/SIPHON INFORMATION Final Grade �6 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft <br /> Forcemain Length Dia. Fi Dist To well <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH width Length No.Of Trenches PIT No.Of Pits InsiDepth <br /> DIMEN I N �� �/ DIMENSIONSde Dia. Liquid <br /> SETBACK <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> INFORMATION Type A G � CHAMBER Model Number: <br /> System: / a So <br /> War OR UNIT <br /> DISTRIBUTION SYSTEM <br /> Header/Mani) ld I Distribution Pip�erys) r !t " x Hole Size x Hole Spacing Vent To Airin e <br /> Length Dia Length L Dia. T Spacing L% — <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil _7] Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS:(Include' code discrepancies, persons present,etc.) <br /> Plan revision requiredE] Yes ItiNo q <br /> Use other side for additional inform4tion.n. <br /> SBD-6710(R 05/91) Date Inspector's Signature Cert.No. <br />