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POWTS INSPECTION REPORT <br /> (ATTACH TO PERMIT) <br /> _ GENERAL IN)FORMATION <br /> Permit Hol er's Name Cit VillageTown of U,oun Sanitary Permit No. <br /> State Plan IQ No. Tax Parcel No. VroperkAddress if Available <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. WENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC <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 C 1 S COVER MATERIAL <br /> Cell Widt Cell Length I Cell Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> Separation <br /> 3aµ 3.Vt - -7-6 <br /> -✓ a <br /> LEA HING AMBER OR UNIT I Manufacturer Co Model No. <br /> Well Lake/Strearn /� � <br /> SETBA INFO. Property Line S '7 Bldg. � — <br /> DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifold D' 'bution Pipe(s) Hole size Hole Spacing Obsv.Tubes <br /> �a Inst. &No. <br /> Length Dia. + Length Dia. Spacing <br /> SOIL COVER <br /> Depth over center of Depth over edge ofDepth of Topsoil ede /Sodded Mulched <br /> cell: <br /> r— <br /> �� � <br /> DEVIATIONS FROM APPROVED PLAN <br /> DATE OF INST. DIRECTIVE: DATE OF ENFORCEMENT ORDER:_ <br /> DATE OF REFERRAL TO LEGAL COUNSEL: _ <br /> COMMEN iPerG�Or�l�lre�t'c� eS <br /> � � pe7';l, <br /> -/goo - <br /> COMPONENTS NOT INSPECTED <br /> Plan Revision Required Date: Signature of Inspector: Cerl:.Number <br /> ZiS <br /> Yes o Sketch on other side <br /> 27 of 28 <br />