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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INFO MATION <br /> Permit Holder's Name 13 Ci Village CKown of County Sanitary Permit 14o. <br /> r <br /> State P an ID No. Ta. Parcel No. Property Address if Available <br /> S1 ba- l a 11ca <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC D ? d > D <br /> DOSING 36.SD >C:21-50 <br /> AERATION <br /> HOLDING <br /> PUMP/SIPHON INFORMATION <br /> Manufacturer: De B r" Model No. Demand in GPM 429fVert. Lift Q <br /> FORCE MAIN INFORMATION FRICTION LOSS <br /> Len tlt Diameter Dist.To Well Component Head TDH-As Bu' t TDH-Design <br /> YL AID, a- z <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT Un I COVER MATERIAL Cr <br /> Cell Width Cell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> 7 Separation <br /> 9 7 <br /> LEACHING CHAMBER OR UNIT Manufacturer Model No. <br /> SETBACK INFO. Property Line 5 bo--I Bldg. Well Lake/Stream <br /> DISTRIBUTION COMPONENT F Elevation data on back of form <br /> Header/Manifold Distribution Pipe(s) Hole size Hole Spacing Obsv.Tubes <br /> Inst. &No. <br /> Lengt Dia. Lengthis Spacing <br /> SOIL COVER <br /> Depth over center of Depth ove edge of Depth of Topsoil Seeded/Sodded Muleftt d i <br /> cell: .&1)0 cell: ' 7 , U 4e `J <br /> EVIAT ORS-FROMAPPR VE <br /> ©bsert1�bAi f 1� avV ,-3 --y .mac <br /> DATE OF INST.DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL TO LEGAL COUNSEL: <br /> .G 4 COMMENTS(Personsesent dis repancies,etc. <br /> '�N Vak,l>, �-A e 15 c7j &k,;2�,�OAI <br /> n T COMPONENTS NOT INSPECTED <br /> Plan Revision Required Dat Signature of Inspector: Cert.Number <br /> Yes o 30 o d� <br /> Sketch on other side <br />