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UNIVERSITY OSTP As -Built Form <br />OF MINNESOTA <br />Owner: D We- 4AV, Parcel Number. 0,41 <br />Street/City/Zip Code: 7 ;P�' AALZ " <br />Lot: Section: Township: N Range: W <br />Installation Date: C — 17 `~ lnstaller:" L License Number: <br />is the system in Shoreland, serving a MDH facility or in a Welhead Protection area? ❑ YES ❑ NO <br />Number of Bedrooms/ Flow Rate: # / gpd Septic Tanks, No & Size: a".Do4 #/gal C' <br />Pump Tank Size: A:�� gal Tank Manufacturer: Pl-ez,4 idf Model # <br />Date of Manufacture: P-0/0 Maximum Burial Depth: ;2-v "-- S 5 <br />Pump Size: hp gpm ft of TDH Floats properly set? ❑ YES ❑ NO <br />Soil Treatment Area: <br />❑ TYPE I 0 TYPE 11 ❑ TYPE111 ❑ TYPE IV ❑ TYPE V <br />❑ TRENCH ❑ BED Rr MOUND ❑ AT -GRADE❑ WARRANTIED ❑ OTHER: <br />Limiting Layer/Depth: " Rockbed Size: Describe: <br />Depth from Surface: " Adsorption width: <br />Rock or Slat depth: Sand depth:, <br />Diameter of Gravelless: " (under mound) <br />Trench Width: <br />10 <br />Bottom Square Feet Area: ftz <br />Design Variances: <br />Site Drawing: <br />p) �- 9,3 North <br />1 115 <br />I <br />P3 A3 <br />-8 L <br />J� <br />,l <br />rem <br />Hb L"2F <br />Items to be Identified: <br />Z. Septic, holding and pump <br />tanks, piping, and soil system <br />configuration. Label bed or <br />trench width and length or <br />rockbed size, absorption width <br />and final dimensions. Indicate <br />alarm location. <br />2. Show all setbacks from tank <br />and soil system <br />a. Property boundries <br />b. Buildings <br />c. Wells <br />d. Water bodies <br />e. Road right-of-way <br />3. Improvements - present and <br />future. <br />4. Benchmark location and <br />distance of tank and soil system <br />from benchmark <br />5. Replacement site <br />6_ Abandoned system <br />Reverse Side <br />