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r:roi�ir County <br /> ^\ os Private Onsite Wastewater Treatment <br /> Ps , Systems ( POWTS) Inspection Report <br /> �— Sanitary Permit No: <br /> (Attach to Permit) Q <br /> Industry Services Division tj 2 2 ' 'U <br /> General Information V <br /> Personal information you provide may be used for secondary pu ses f Privacy Law,s.15.04(1)(m) <br /> Permit Holder's Name: LJ City Lj Village Town of: State Plan Transaction ID#: <br /> Pau'k Gl oarS�i (CL &q(.0 y7$ <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> -Foe 4 Corice c--fie S l 0-b 3 u cc 3 5 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road <br /> Septic $. r ( y . U`i , 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 Manufacturer Filter Model GPM Benchmark 3 tog .-7 100 <br /> L;k,-H LT ll 19 <br /> TDH Lift Friction Loss Head Total Bldg.Sewer Le _d 1 97 (Q9 <br /> Forcemain Length Dia Dist.To Well Tank Inlet 7 <br /> Tank Outlet U .�{5 25 <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Width 31 Length #of Cells Dose Tank Bottom <br /> SETBACK FROM Prop.Line Buildin�q Well OHWM Inst.Contour <br /> S 1 5 ".5,q +5D Header I Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe <br /> r <br /> L Z �f DbIJ Model Number:EZ f 2DU Infiltrative Surface y 5 %. Z 5 <br /> Pretreatment Unit llJ Final Grade -17 019,23 <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 ❑Yes ❑No <br /> Soil Cover <br /> Depth Over Depth Over Depth of Seeded I Sodded Mulched <br /> Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑No <br /> COMMENTS:(Include code discrepancies,persons present,etc.) <br /> Plan revision required? ❑ Yes ANo Op lq �27 15ts SU-71 <br /> Use other side for additional information. f t <br /> Date POWTS Inspector's Signature License Number <br /> won c7411 io n�io� <br />