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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> GENERAL INFORMATION <br /> Permit Holder's Name Cit [] Village own of County Sanitary Permit No. <br /> State Plan ID No. ax Parcel No. Pr p rty Address ' <br /> o3a-5 - <br /> TANK INFORMATION SET ACKS <br /> TYPE MANUFACTURER CAPACITY P/11WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> 011 <br /> SEPTIC 7.50 <br /> DOSING s K -60-01 }o2S > o 1c4 <br /> AERATION _ _ <br /> HOLDING <br /> PUMP!SIPHON INFORMATION <br /> Manufacturer: j AJU,. -C Model No. Demand in GPM Vert. Lift O <br /> FORCE MAIN INFORMATION FRICTION LOSS s 77 <br /> Lenath Diameter Dist. To Well Component Head TDH-A 13uilt TD Design <br /> d-0 <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT - COVER MATERIAL j rc <br /> Cell Width FCell Length Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> 7 / �f�- 1.?a / Separation <br /> LEACHING CHAMBER OR UNIT Manufacturer Model No. . <br /> SETBACK INFO. Property Line � Bldg. 5 30 Well 510' ILake/Stream <br /> DISTRIBUTION COMPONENT/Elevation data on back of form _ <br /> Header/Manifold Distribution Pipe(s) a2, Hole size Hole Spacing Obsv. Tubes <br /> V 11 Inst. &No. <br /> Length 3 Z I Dia. 09 Length C) I Dia. Spacing <br /> SOIL COVER <br /> pth over center of Depth over edge of Depth of Topsoil Seeded/Sodded Mulched <br /> 1: �� cel ,©® <br /> DEVIATIONS FROM APPROVED PLAN <br /> po Jell 0r5 '�1' Ve, Yne- df- j551i , tY15�I/d7W1 <br /> DATE OF INST. DIRECTIVE: DATE OF ENFORCEMENT ORDER: _! <br /> DATE OF REFERRAL TO LEGAL COUNSEL: _ <br /> 1 �u COMMENTS(Persons present, discrepant' ,etc {� za�e%18 d <br /> 4 e ho <br /> mi 1 I�S ' Sc�ed�e m/ CLQ r�f .t7 <br /> COMPONENTS NOT INSPECTED <br /> Plan Revision Required Date: �i Signaturf;of Inspector: � Cert.Number <br /> ❑ Yes [] No <br /> Sketch on other side <br /> �S �AV <br /> S <br /> �nr1 p <br /> 27 of 28 <br /> ,�f �'- a I <br /> OJ o d Wow <br />