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N <br /> O <br /> CITY OF isig ism . <br /> MID Orono 1.1111.1• MN TOa <br /> g? <br /> p ,, o X <br /> Location of job �r) \-,U``Q+`G ` o <br /> Y a <br /> Owner %J Jt \-\4.t„Z'S !Address i2,. <br /> Licensed Designer S.C.” —re.0- .r.tS Sr. . . License# (a 21 <br /> Licensed Installer -C.,-.: s'N$ S-e_ . (Y License# `( i A <br /> Signature <br /> Date 11/1-tofl3 <br /> (Show location of house, tank, drainfield, property line and well) <br /> N <br /> �1`w <br /> vv._ <br /> _F E <br /> I <br /> k ' <br /> ,� �t � � <br /> ; f <br /> ,/7R� �f <br /> (01 <br /> 1 <br /> , T <br /> n <br /> , I <br /> ,t r___________ ) ei 0 4 jill' <br /> L........, -..f4,1,. . , ,......... .... -0 <br /> ,.;,,,,..„ , <br /> ``"m.„ <br /> NOTE: On ALL replacements and additions, tanks must be exposed for baffle inspection. <br /> COMMENTS: .iA." - v.,1 a(f " t 2 11 o a-- c.43-- 1'Y \-\o" s-Q At) -let <br /> New Work A Outside Lift ji <br /> Replacement ❑ Ejector ❑ <br /> Addition ❑ Gravity ❑ <br /> Mound System;it' <br /> Tank Size 3 -- 2ei4 <br /> 0 DATE - <br /> Tank Size INSPECTOR <br /> Square Footage of Drainfield Area 650 <br /> Depth of Rock Under Pipe '"f" COMMENTS <br /> Depth of Rock Over Pipe 2'' <br /> Graveless `� <br /> Depth of Dirt Cover 1 g`, <br /> Number of Bedrooms 5 c 'y' <br /> THIS FORM MUST BE FILLED OUT BY A LICENSED INSTALLER (ASBUILT) <br /> (l)CITY COPY, (2) OWNER COPY, (3) LICENSED INSTALLER COPY <br />