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MDH USE ONLY <br /> � MQMYESOTA DEPARTMENT OF HEALT[i Date Received <br /> Well Manageme�t Se�ion Amount Received <br /> P.O.Box 69502 Application No. <br /> SL Paul,Minnesota 55164-0502 ❑ $235 Vertical Heat Exchaz►ger<10 Tons (493n <br /> � 651-201-46D0 or 500-383-98Q8 ❑ $475 Vertical Heat Exchanger 10 W SQ Tons (4938) <br /> Fax No. 651-20[-4599 <br /> Deaf and hard-of-hearing: TTY 651-201-5797 ❑ $700 Vertical Heat Exchanger>50 Tons (4939) <br /> Schematic of Plumbing Design <br /> Applicattoa fo�per�it to iostsli a vertical heat exchsage device(esrth- ���� Approved <br /> conpl�i h�t loop)pursaant to Minnesota Statvtea,Chapter 103I aed Site Plan Showing Isolation Distances <br /> rules adopted t6ereuoder. Received Approved <br /> Logs of the Holes,if Existing <br /> (IYOTE: Make check payable to: Minnesota Department of Health) <br /> Indicate Heating/C�ling Capacity: ❑<10 Tons �10 w 50 Tons ❑>50 Tons <br /> Geaeral Project Data to he completed by a11�plicants(please print or type all information provided). <br /> Name of Certified Representative DBVId P. H@I1riCh Cectified Repr�esentative No. 1205 <br /> Company Name Bergerson-Caswell, InC Company License No. 1767 <br /> Telephone No.(including area code) 763-479-3121 <br /> s�t pddr�s 5115 Industrial Street <br /> ciry,sr�ce,ana z�coae Maple Plain, MN 553359 <br /> applies for a permit to install a vertical heat exchanger device(e�rth-coupled heat I�p)as hereinafter set form or as disclosed by <br /> atf�ched supporting data. <br /> 1. A.Legal D�cription of Verti�l Heat Eachanger(VHE). <br /> Township Range Section Quarter(s) <br /> County Township Name No. No. No. Smallest—�Largest <br /> Hennepin Orono 117 23 7 NW '�4SE '/4NW !4 !4 <br /> B.VHE Imcatioa Site Address <br /> Address <br /> 315 North Shore Drive <br /> City S� ZIP Code <br /> rono MN 55364 <br /> 2. VertiCal Heat Eachanger Owner Mailing Addr�s. <br /> Name <br /> �P.P.ii7 C L.�N D <br /> Address <br /> �l3/S' NvRTy s o� Q�vE <br /> C� g� ZIP Code <br /> OQonia /Y1 N s"S <br /> 3. Property Owner Addr�ss(if different t6an the Vettical Heat Facchanger Owner Mailing Address). <br /> Name <br /> Address <br /> Cily <br /> State ZIP Code <br /> � <br />