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p RTA, <br /> =r Private Onsite Wastewater Treatment �✓ <br /> >. 'a County <br /> Systems ( POWTS) Inspection Report <br /> R,,,;, 4� (Attach to Permit) Sanitary Permit No: <br /> industry Services Division , 1 <br /> General Information ' ''�v- Z'- I gcl <br /> Personal information you provide may be used for secondary purposes Privacy Law,s.15.04(1)(m)i <br /> Permit Holder's Name: 0 City 0 Village ,Town of: State Plan Transaction ID#: <br /> tct S NJ-Ur M-Rext°''' Parcel Tax No: <br /> CST BM Elev: lnsp BM Elev: ! BM Description: <br /> 1ODI 'rcP 63 tftSLi 12(0 31 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road <br /> Septic N/A <br /> Dosing N/A <br /> Aeration N/A <br /> Holding (/•)jQ.S-Uf" 2ctb 4 2' t 25' + ' <br /> Pump I Siphon Information NJ p Elevation Data <br /> Pump Manufacturer Pump Model Demand STATION BS HI FS ELEV <br /> Filter Manufacturer Filter Model GPM Benchmark 1,y j i pt,y 2 /co <br /> TDH Lift Friction Loss Head Total Bldg.Sewer 3 . tp 9•$2 <br /> Forcemain Length Dia Dist.To Well Tank Inlet LI. ?j 91. )2 <br /> Tank Outlet <br /> Dispersal Cell Information N A Dose Tank Inlet <br /> DIMENSIONS Width Length #of Cells Dose Tank Bottom <br /> SETBACK FROM Prop.Line Building Well OHWM Inst.Contour <br /> Header 1 Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe <br /> Model Number: Infiltrative Surface <br /> Final Grade <br /> Pretreatment Unit NA Li 2 100 <br /> Manufacturer: Q,S R.✓ 1' <br /> Model Number: <br /> Distribution System IVA X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes <br /> Length Dia Length Dia Spac Spacing ❑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 ❑ No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> DICt n y -{ .n k -Fof pr'Drokd -ru-It.ve h,ou-3-1z- <br /> `n id Plc <br /> Plan revision required? ❑ Yes a(No Op I y 2o2� /5(0 (ql <br /> Use other side for additional information. t) <br /> Date POWTS Inspector's Signature License Number <br />