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� � .�r�i�b�ok� <br /> � RECEIVE;� <br /> �-�; ��os � <br /> �'���� �, �EP 2s zo�4 <br />/ C�i T Y C)f- �RC)I��n,c� oRo <br />( , �vo <br />� �t y� Strr�;llc�tfraxs: � M1�tailireg.4ddr�,.: 7 '�t�r��er�e�951�229116Q0 <br /> '\� �r 2754Kelley Parkway P,fJ.Hau 66 F Y �S?' J4�a iG'b <br /> �,�q i� U�;i4 N�J '✓a,iSb �ry�t�'' lssy: hiN�S.SZ3 wrv.� .-v r it• ��� <br /> 'ff 1110R , <br /> Septic System Permit Application <br /> Please complete this applicaton completely. Failure to fill in all of the required information may <br /> result in a delay of processing your application. Submit this application, a complete copy of the <br /> site evaluation and the design at least 3 working days prior to the projected installation date. <br /> Pro Owner: ��k� �•:� �r�.�S Email: <br /> Mailin Address: - lo �L 7 � () <br /> -- <br /> Phone: Cell: Work: Home: <br /> Des' ner: �5 n lSvr� License# $jU Email: Phone:7 � - �1�/ <br /> InstalleNContractor: i� C �-SLicense# (p �Email: Phone�� � � - � �- <br /> Date to be Installed: <br /> Pro Address: g ��� � `� <br /> Existin Se tic S stem E es: Yes No � � <br /> Parcel: (,�no address) C�l�1 / <br /> General Lot Dimensions: Width: De �rsq ft) � <br /> Home T e_ F� � #of Bedroor Water Cond: <br /> � _.._.._---- <br /> Garba e Dis sal: > Ho.�_ hir ol: <br /> We7T: Existin New to be installed ...,,., . ue th of Casin : <br /> PROPOSED SEPTIC INFORMATION �L,�y��:�,,,5 <br /> Soil Types: � �v✓� w� Sizing Factor: ` <br /> Septic: New Replacement Addition Other t�"�'"�`� <br /> Tanks: Q t t p:--�- New �Z� Existing Total � I2�5� <br /> Tank Type e;;��� � Capacity L- I3ov Manufacturer f ,,�,�, ;,,, V <br /> Pump Station: Tank Type ��c:,rc�c Capacity j 3�� Manufacturer 9-v w;'�.. � <br /> e � <br /> (if applicable) Pump Size p � 7� . Type 3(v C�Ph^ Failure Alarm Type (Q���j2.,.� '� <br /> Drainfield Total Length� Total Width � Maximum Depth �, <br /> Trenches w/rock Trench w//chambers U <br /> Rock below pipe 9 in K <br /> Pressure Bed Mound •�`"" Other(explain) � <br /> � <br /> Mound Dimensions: Rock Bed '�u x � ft Absorption Area ��Z x �� ft �„� C r � <br /> Clean Fill below rock bed �inches <br /> Filter: Type '--� Manufacturer — Alarm Type`— <br /> New designs shall adhere to 2008 MPCA standards. <br /> OFFICE USE ONLY <br /> Permit# �/�/-D�O�� Payment Rec'd Zoning District <br /> Field Checked Date Inspected New/Replace <br />