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As PRIVJ kTE ONSITE WASTE TREATMENT SYSTEMS <br />non Pow rs <br />Department of Commerce INSPECTION REPORT <br />So" ON Buddings Division <br />(ATTACH TO PERMIT) <br />GENERAL INFORMATION <br />- o ..,`.. ,.., <br />Permit Holder's Name: <br />- ,V= <br />I rnvRCY Law, 8, IS.U4 I m <br />El City 13silage Town of: <br />Ui' 1,eeln BaKpIr <br />Do f <br />CST BM Elev: <br />Insp M Eiev <br />BM Description: <br />o0 <br />6AAA E-'I <br />&rro" OF sipjiv& <br />'rA UV IkAr/ A%1IAA <br />TYPE <br />MANUFACTURER <br />CAPACITY <br />Septic <br />F,usn <br />Oosi.ng <br />- <br />TM <br />Aeration <br />Holding <br />TANK TO <br />PJL <br />WELL <br />BL GG <br />°, <br />ROAD <br />sew <br />%3li <br />NA <br />x <br />30 <br />NA <br />R <br />NA <br />PUMP ! SIPHON INFORMATION <br />Manufacturer <br />Demand <br />GPM <br />Model Number <br />TDH -Lift <br />Friction Loss <br />Sys <br />Head <br />TDH Ft <br />Forcemain <br />Length <br />Di <br />I Dist <br />To Well <br />Y1�7rCRlML I.CLL 1mr-1]KM0 111 Jim <br />DIMENSIONS <br />Width <br />Length <br />No of Cars z <br />SETBACK <br />INFORMATIONP <br />/ L <br />Bldg <br />WON <br />OHWM of Nay <br />WaN n <br />CELL TO <br />Tom- ' <br />x <br />x (o$ <br />5/ <br />VIJ I RIOU 1 IVPI ,T51 trd <br />Header / Manifold <br />Length D_ia I Length_ <br />SOIL COVER <br />Depth Over Depth Over <br />Cell Center Cell Edges <br />COMMENTS: (Include code discrepancies, r <br />Permit Posted? (y) N <br />Schedule 40 Vents and Obsery <br />Cover Material: -rV PA R <br />Effluent Filter Manufacturer <br />Components Not Inspected: <br />Dia <br />■ a1qa i_1 rl9l; rreA r"t <br />Bumett County <br />Propeny Address: b <br />San ary Permit No: <br />86't <br />State Plan Transaction IDO: <br />Parcel Tax No: <br />_oS_ <br />STATION <br />BS <br />HI <br />FS <br />ELEV <br />Benchmark <br />p <br />/ 0/, 30 <br />/gam 00 <br />Bldg. Sewer <br />,VIA <br />St / Ht Inlet <br />VIA <br />St / Ht Outlet <br />/A <br />Dt Inlet <br />u/A <br />Dt Bottom <br />Installation <br />Contour <br />Header I Man, <br />Dist Pipe <br />, i 7 <br />9 <br />infiltrative <br />Surface <br />10 <br />95..z0 <br />Final Grade <br />Type of System Manufacturer: <br />(S-onvar ian2l LEACHING <br />In _9 AX4,,'t CHAMBER Model Number: <br />X Pressure Systems Only <br />X Hole Size X Hole Observation Pipes <br />Spacing ❑ Yes ❑ No <br />❑ Yes ❑ No <br />Mulched <br />Yes 0 No <br />present, etc.) 501"(- 7anK Aufl PutKP C"ber AV'z ews-n"' J,%A <br />5'+Q FwLet"KA), b„f,- Pnt� 4hsm,6ee m ?#416'aL-<v "+y <br />Pipes?&Y N 4"4 rt6-'6ce.l"-d im tlr.^r 44we- 4!9� <br />Model vm <br />Plan revision required?O Yes O No �71 O 07% <br />Use other side for additional information Date qOZWTS Ins or's Signature <br />1-71 0 f 3 I <br />Cart No <br />