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cts�Rrsr; \ County <br /> Private Onsite Wastewater Treatment gURNETT <br /> Ps���:� Systems POWTS Inspection Report <br /> -1.*f (Attach t) Per pt) Sanitary Permit No: <br /> .` <br /> Industry Services Division <br /> General Information SAN-25-42 <br /> Personal infonnation you provide may be used for secondary u oses I Privacy Law,s. 15.04 1 (m <br /> Permit Holder's Name: Ij City Lj Village x Town of: State Plan Transaction ID#: <br /> JON AND ANN DIETMAN OAKLAND 662188 <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> 100, NAIL IN 20" OAK 14670 <br /> Tank Information setback to: <br /> TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road <br /> Septic INFILTRATOR 1000 >2' >25' 6' 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 1.70 101.70 100 <br /> LIFETIME <br /> TDH Lift Friction Loss Head Total Bldg. Sewer 5.05 96.65 <br /> Forcemain Length Dia Dist.To Well Tank Inlet 5.59 96.11 <br /> Tank Outlet 5.80 95.90 <br /> Dispersal Cell Information Dose Tank Inlet <br /> DIMENSIONS Width Length #of Cells Dose Tank Bottom <br /> 3' 130' 1 <br /> SETBACK FROM Prop.Line Building Well � OHWM Inst.Contour <br /> >5' >10' >50 >50' Header/Manifold <br /> Type of Cell Manufacturer: <br /> Distribution Pipe <br /> EZ-FLOW Model Number: Infiltrative Surface 6.70 95.00 <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.) <br /> Plan revision required? ❑Yes I7 No 05 07 2025 1 10041 - PI <br /> Use other side for additional information. <br /> Date POWTS Inspector's Signature License Number <br /> SBD-6710(R.03/21) <br />