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1 ; 30 <br /> POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION <br /> Permit Holder's Name 0 Qjty VillageTown of Coun mita e it No. <br /> State Fla D No. Tax P 1�No Prope A ss if Av ilable <br /> �, <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC e �S� y �O� > a2eaY <br /> DOSING e5eCoU <br /> AERATION <br /> HOLDING <br /> PUMP/SIPHON INFORMATION <br /> Manufacturer: Model No. Demand in GP L� Vert. Lift <br /> FORCE AIN INFORMATION FRICTION LOSS ZS <br /> Length Diameter Dist. To Well Canponent Head TDH -A B 'It TDH sign <br /> act. <br /> 610%- <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT C I COVER MATERIAL <br /> AIA- <br /> Cell Width Cell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> Separati n <br /> LEACHING CHAMBER OR UNIT Manufacturer /Weir— I Model No. . <br /> SETBACK INFO. Property Line 7/&V Bldg.__> Well -2 Lake/Stream <br /> DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/)M��aj�ifo�ld/ ism�utio Pipe(s) Hole size I Hole Spacing Obsv. Tubes <br /> Sel icL1 �tlQu/ glAn, Inst. &No. <br /> Length Dia. h Length Dia. Spacing 11 <br /> SOIL COVER <br /> Depth over center of Depth over dge of Depth of Topsoil e /Sodd Mulched <br /> cell: ? �.00� cell: 7 , <br /> -------- <br /> DEVIATIONS FROM APPROVED P AN <br /> DATE OF INST.DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL TO LEGAL COUNSEL: <br /> COMMENTS (Persons pr se ,discr;pancigs,etc.) j <br /> l�obeirf"C2►-IS°A/� � 1,,,, �/�i' �'i'luSrtn''all �/��7�Y' <br /> LJ0-rite � 1� ol, 1nAt7j /e (40 Z_ _,rl ' �'Ul er//4 <br /> COMPONENTS NOT INSPECTED <br /> Plan Revision Required Date: Signature of Inspector: / Cert.Number <br /> Yes o 0 ` 2 Z Yo5 <br /> Sketch on other S <br />