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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INF RMATION J]IS�anitPe7itFNo. <br /> Cit Village Town of County <br /> Perm H r Nam Y <br /> State Plan ID No. Tax Par No. Property Address if Available <br /> TANK INFORMATION <br /> TBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC ee <br /> DOSING <br /> AERATION 0 , Z r y <br /> HOLDING 1Ce 5 v <br /> PUMP/ ON 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 CUVER MATERIAL <br /> Cell Width Cell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> � Separation <br /> vg05a' <br /> Model No. . i' 2G1� <br /> LEACHING CHAMBER OR UNIT Manufacturer i Well ake/ tream <br /> SETBACK INFO. Property Line Bldg. d <br /> rm <br /> DISTRIBUTION COMPONEN /Elevation data on back of fo <br /> Header/Manifo r, P tribution ( ) Hole size Hole Spacing Obsv.Tubes <br /> /0 #1 /1 1 � � Inst. o. <br /> Length Dia. Length Dia. Spacing <br /> SOIL COVER — <br /> Depth over center of Depth over edgeDepth of Topsoil Seed. /Sodded <br /> Mulched <br /> cell: -d2 cell: `1 $� / Ge "— <br /> r'4�a( re�w1^ee(VI rI <br /> e- <br /> '41, R'yts OM I,w ldVf/DFI� P �r{^CP,J�7 <br /> � � �,,� <br /> DA11 TE OF 1NST. DIRECTIVE: DATE OF ENFORCEMENT ORDER: <br /> TE OF REFERRAL TO LEGAL COUNSEL: <br /> CO M NTS(Per ns resent, iscre ncies,etc.) <br /> �4U i'd rfr s�l� u e �6 ��,.� ► <br /> Gvic <br /> �e I�h►t � ( 6Sfeo� � � W <br /> ECTEDO NT�NOT S <br /> 67G 4Sl <br /> Ce be <br /> Plan Revision Required Date: Signature of Inspector: d <br /> Yes No <br /> Sketch on other side <br />