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I <br /> POWTS INSPECTION REPORTX�; I r!� <br /> (ATTACH TO PERMIT) <br /> GENERAL INF RMATION <br /> Permit Hold 's Name City Village Town of o unty San iitaryPermit No. <br /> (ores andal ee Cl <br /> State Plan ID ' �/ Tax Parcel No. Property Address if Avai ble <br /> n <br /> TANK INFORMATION SETBACKS <br /> TYPE MANUFACTURER CAPACITY P/L WELL BLDG. VENT ROAD <br /> TO AIR <br /> INTAKE <br /> SEPTIC -7—c:�o W <br /> DOSING 7 <br /> AERATION <br /> HOLDING <br /> PUMP/SIPHON INFORMATION <br /> Manufacturer: 1-00"qtVc-j Model No. o—a Demand in GPM Vert. Lift <br /> FORCE MAIN INFORMATION FRICTION LOSS O� <br /> 11 ,To Component Head TDl ASS ilt TDH Design IoDiameter q Dist. O/o <br /> SOIL ABSORPTION COMPONENT <br /> TYPE OF COMPONENT y^d Cie It I COVER MATERIAL F" r e b <br /> Cell Width Cell Length Ce 1 Diameter Cell Depth Horizontal Liquid Depth No. of Cells <br /> / 7�� /0 / Separ —_-- <br /> LEACHING CHAMBER OR UNIT Manufacturer Model No. . <br /> SETBACK INFO. Property Line Idg. Lake/Stream 7 - <br /> 0T-DISTRIBUTION COMPONENT/Elevation data on back of form <br /> Header/Manifold Distribution Pipe(s) Hole size Hole Spacing Obsv. Tubes <br /> 2 Insj. 81 No. <br /> Length Dia. I Length Dia. Spacing <br /> SOIIL COVER <br /> Depth over cr of Depth over a ge of� Depth of Topsoil Seeded/Sodded Mulched <br /> cell: /' cell: 7 v <br /> DEVIATIONS FROM APPROVED PLAN <br /> DATE OF INST. DIRECTIVE: I DATE OF ENFORCEMENT ORDER: <br /> DATE OF REFERRAL TO LEGAL COUNSEL: <br /> COMMENTS(Persons present,discrepancies etc.)�+ <br /> Pern�i pdS J� L/ GoG/(i Lb!/HhS OYeY f-007�z /Lo <br /> bV11 le lxla'o-iO 1041 0nG("Z� � /��O �hS�eC <br /> COMPONENTS NOT INSPECTED <br /> Plan Revi6o equired Date;,�O�^O Signature of Inspector: Cert.]m <br /> ❑ Yes No <br /> Sketch on other side <br /> 27 of 28 <br />