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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> _ GENERAL INF RMATION _ <br /> ' it Holder's N<lcrte Ci Village Town of County Sanitary Permit No. <br /> n Lrako Jam - ' <br /> State Plan ID No. Tax Parcel No. Property Address if Available <br /> ---- 61 - 5- oN- a?02 6 7 r� <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY PLT, WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC <br /> DOSING <br /> AERATION -- <br /> HOLDI_N_G <br /> PUMP/SIPHON INFORMATION <br /> Manufacturer: +Model No. — GPM Vert.Lift <br /> FORCE MAIN INFORMATION_ FRICTION LOSS <br /> LengiEDiameter Dist.To Well Component Head TDH-As Built TDH-Design <br /> —_�— — <br /> OI ABS RPTION COMPONENT <br /> TYPE OF COMPONENT _- !` COVER_MATERIAL <br /> Cell Width Cell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> / / ��� Separation <br /> 3 8 , 30-11 --�- 1- <br /> 'TEACHING CHAMI OR UNIT Manufacturer h m Model No. (' M e w,)1VI /- <br /> SETBACK INFO. Property Line Bldg. , Well Lake/Stre <br /> _DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifold Distributio Pipes) Hole size Hole Spacing . Obsv.Tubes <br /> - fy 1� Inst.&No. <br /> Length _ Dia. Length ca. Spacing --� <br /> _ SOIL COVER <br /> Depth over center o Uepth ove edge of Depth of Topsoil eede /:kidded Mulched <br /> cell: � �cell: f�� —"� �_ _ <br /> E TIONS FROM APPROVE PLAN <br /> Bh1 - e(evaAo GG�yy' ko-F corm o>d te-- C�ev��c earcI^� <br /> S� � <br /> DAT OF_INST. DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL TO LEGAL COUNSEL: <br /> COMMENTS(Persons pre ent,qiscrepaxicies, etc.) /2 L <br /> ----- „.�-� zebe,( 64-10 �hd' e�,�7�ihc� <br /> — MPONENTS NOT INSPECTED <br /> Plan Revision RKaired - Dat :'/6 Signature of Inspector: Cert.N robber <br /> Yes_ <[Cl - <br /> Sketch on other sid <br /> 27 of 28 <br />