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POWTS INSPECTION:REPORT <br /> (ATTACH TO PERMIT) <br /> __ _ GENERAL INFORMATION <br /> 'ermtt l.. o1 er's — e — T Cc Village XTown of Count— anu ermit No. <br /> State Phut:[D No. Tax Parcel No. Property Address if Available <br /> 63a-Saa �'�_ _ 3oa_e�s C/io�Jo-1ivserh <br /> TAN:K INFORMATION ___SETBACKS <br /> TYPI MANUFACTURER CAPACITY PLL WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> DOSING <br /> AERATION -------- ------ <br /> HOLDING <br /> PUNIP/SYPHON IN]FORMAT'ION <br /> Manufacturer: _— Model No_---N___� Demand in GPM Vert. Lift <br /> FF E Ni[_F►IN INFO_RZA7T ON FRICTION LOSS <br /> Length Diameter Dist. To Well Component head I TDFI•As Built TDH-Design <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT _Z� I OVER MATERIAI,_--T-n <br /> Cell WidthEj <br /> Cell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> -_ VBERORUNIT <br /> ,r� / i I 1 Separation <br /> -- -�--� --- -- --- --1-=— <br /> LEACHING C:[IAIManufacturer _ Model No. <br /> SETBACK,INFO. Property Line 7 5_ Bldg. � __ — well Lake/Stream 5 <br /> ----DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifold Distribution Pipe(s) Hole size Hole Spacing . Obsv. Tubes <br /> Inst. &No. <br /> Length --�—Dia. Length Dia. Spacing -_--� <br /> _ SOIL COVER <br /> Depth over center of Depth over edge of Depth of'Topsoil rSeeded/Sodded Mulched <br /> cell; cell: <br /> _--- ------_--1- - <br /> DEVIATIONS FROM APPROVED PLAN — <br /> DATE;OF )ATE—__—_ LATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL,TO I.EG_A_L COUNSEL: <br /> / . r COMMENTS(Persons present,,discrepancies, etc.) <br /> _�JD_h n -I ' f f� t7rtO� - <br /> - --------- COMPONENTS NOT INSPECTED — <br /> Plan Rev 'qRequired — Datppc: �yy Sign�a 9a of Inspector: — — Cert.Number <br /> {� Yes to----- .._L11drt1---- <br /> Sketch on other side <br /> 27 of 28 <br />