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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL <br /> -INFORMATION <br /> Permit Hol is Name Ci Village Town of County738LIC)IR <br /> Sanitary Permit No. <br /> �u r <br /> State Plan ID—No. Tax Parcel No. Property-Address ddress if Available <br /> old-4aa - O -l� 3Ll�lPDAA <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC QY'wesc as 7 0 > % > $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 rr COVER MATERIAL <br /> Cell Width Cell Length CellEliameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> ^ 0�0 Separation <br /> LEACHING CHAMBER OR UNIT Manufacturer Model No. <br /> SETBACK INFO. Property Line Bldg. o Well Lake/Stream 5/70 <br /> DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifd Distribution Pipe(s) // Hole siz Hole Spacing Obsv, Tubes <br /> Y 1 Inst.4 No. <br /> Length Dia. 1 Length Dia.VP I Spacing f Z8w <br /> SOIL COVER <br /> Depth over nter ofr Depth over edge of Depth of Topsoil Seeded/Sodded Mulched <br /> cell: �S cell: > /. ;LS <br /> DEVIATIONS FROM APPROVED PLAN <br /> DATE OF INST.DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFE-RRAI,TP LEGAL COUNSEL: <br /> COMMENTS(Persons present, discrepancies,etc.) <br /> a- <br /> COMPONENTS NOT INSPECTED <br /> Plan Revision quired. Date Signature of Inspector: . Cer,. Number <br /> Yes o Z 6 <br /> Sketch on other s' <br /> 27 of 28 <br />