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w:sconsM Departmentof Industry, PRIVATE SEWAGE SYSTEM county: <br /> Labor and Human Relations INSPECTION REPORT r e <br /> Safety a0d Buildings Division <br /> (ATTACH TO PERMIT) Sanitary Permit No <br /> ,GENERAL INFORMATION a � <br /> Permit Holder's Name: 0 City ❑ Village own of: State Plan ID No <br /> av un1 ceJlss �—" <br /> CST BM Elev.: Insp.BM Elev.: BM Descri do Parcel Tax No.: <br /> -7 Alnufa So - OA tic <br /> TANK INFORMATION ELEVAT ON DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. <br /> Septic SSK CokiCrefe 00 Benchmark <br /> Dosing <br /> Aeration Bldg.Sewer (p, <br /> Holding St/Ht Inlet -7, (71010 <br /> TANK SETBACK INFORMATION St/Ht Outlet ,& <br /> TANKTO P/L WELL BLDG. Vent to <br /> Air Intake ROAD Dt Inlet <br /> Septic �56139_7 I 9 NA Dt Bottom <br /> Dosing NA Header/Man. '7. 70 6.36Q <br /> Aeration NA Dist. Pipe 779 <br /> Holding Bot.System Q s, (A0 <br /> PUMP/ SIPHON INFORMATION Final Grade !94 <br /> Manufacturer Demand <br /> Model Number GPM <br /> TDH Lift Friction System TDH Ft Loss <br /> Forcemain Length Dia. ead H Dist.Towell <br /> SOIL ABSORPTION SYSTEM <br /> BED/TRENCH Width Length /_ No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth <br /> DIM I N /a 3 (0 "'�" DIMEN I N <br /> SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: <br /> SETBACK <br /> INFORMATION Type <br /> Co B(� 7`0 , Jr� {� OR UNIT CHAMBER Moa Number: <br /> DISTRIBUTION SYSTEM <br /> Header/MC <br /> ,/ bl Distribution Pipe(s) lr / x Hole Size x Hole Spacing Vent To Air Intake <br /> (� z� pq V <br /> Length Dia. Length J oa Dia. Spacing <br /> SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only <br /> Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched <br /> Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No <br /> COMMENTS: (Include code discrepancies, persons present,etc.) <br /> �- r� � - /J <br /> E(eUa4ron5 +dil9le�l S ons �ro�iced `°y L✓ac�e /`4Js/7o�� // e C7nr�i�oI/a� <br /> Plan revision required? 0 Yes 't No <br /> Use other side for additional inforn ation. 8 IY 1�z <br /> SBD-6710(R 05191) Date Inspector's Signature Cert.No. <br />