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. /, rna7.kr County <br /> n Private Onsite Wastewater Treatment <br /> ps Systems ( POWTS) Inspection Report &, <br /> — ,x <br /> (Attach to Permit) Sanitary Permit No: <br /> Industry Services Division y�General Information - �(p7 <br /> Personal information you provide may be used for secondaryu oses Nvac Law,s.15.04(1)(m) <br /> Permit Holder's Name: LJ City Lj Village Town of: State Plan Transaction ID#: <br /> k�e� U k rvt� ��V rtru <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> I GG' 5 �pP Ise o,hove ' . ,r4i c 4- A <br /> c�-ate+ <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop.Line Well Building Air Intake Road <br /> Septic ( L 7' 3 2 L. 2' 22 , N/A <br /> Dosing N/A <br /> Aeration N/A <br /> Holding <br /> Pump/Siphon Information Elevation Data <br /> ump Manufacturer Dump Model Demand STATION BS HI FS ELEV <br /> Filter Manufacturer Filter Model GPM Benchmark ,75 10U S CO <br /> I K PC-`D25 <br /> TDH Lift Friction Loss Head Total Bldg.Sewer <br /> Forcemain Length Dia Dist.To Well Tank Inlet N�� 3 i✓� .___� 5, `j5• �, <br /> Tank Outlet X )Ppp 3•(X-2 QJ-5 5 9 7• <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Width Lenath #of Cells <br /> 50` 501 � Dose Tank Bottom <br /> SETBACK FROM Prop.Line Building Well OHWM Inst.Contour `J <br /> 4 5 32 t `-�D Header/Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe -2 <br /> Model Number: Infiltrative Surface <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 Spacing ❑Yes ❑ No <br /> Soil Cover <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑ No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) fi <br /> (P"-15 = fioe cl Sc�,r\j c N Z ri)wS 04 �eA /lAct✓ <br /> 4J tV)cl Sp fj C Moir I n h a-t Ste. <br /> Plan revision required? ❑ Yes�No loglqi �nZ2 ,J 151 5(,Q 7Use other side for additional information. l,1) J `"� �l <br /> Date POWTS Inspector's Signature License Number <br />