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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INYORMATION <br /> Pe it Ho}� 's Name qty Village wn of CountySanitary Permit No. <br /> State P`laan ID No. Tax P cel N Property ddress if Availabl <br /> b3 -� s-83-44 Laos <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC re co.51— d0 6 /Bo' o s o <br /> DOSING <br /> AERATION <br /> HOLDING <br /> PUMP/SIPHON INFORMATION <br /> Manufacturer: Model No. Demand in GPM Vert. Lift <br /> FORCE MAIN INFORMATION FRICTION LOSS <br /> Length Diameter Dist. To Well Component Head TDH-As Built TDH- Design <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT I COVER MATERIAL <br /> Cell Width Cell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> Separation <br /> LEACHING CHAMBER OR UNIT IManufacturer Model No. . <br /> SETBACK INFO. Property Line Bldg. Well Lake/Stream <br /> DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifold Distribution Pipe(s) Hole size Hole Spacing Insv. Tubes <br /> nst. &No. <br /> Length Dia. Length Dia. i Spacing <br /> SOIL COVER <br /> Depth over cen-terod Depth over edge of Depth of Topsoil Seeded/Sodded Mulched <br /> cell: cell: <br /> DEVIATIONS FROM APPROVED PLAN <br /> DATE OF INST. DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> D TE OF REFERRAL TO LEGAL COUNSEL: <br /> COMMENTS.( s present,resent,discrepancies,etc.) <br /> s <br /> ��✓�fi��la I �a f� + AS bu,'/ a� 'li�. /e r �pu� flaw/�hs, <br /> l L COMPONENTS NOT INSPECTED <br /> .14��� Se�;l�c �A'hl�•. <br /> Plan Revision Required Date: Signature of Inspector: Cert.Number <br /> Yes No � <br /> Sketch on other side <br />