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<br /> Septic System Permit Application
<br /> PieasE completE this appiicatan compl�tely. Failure to fii! in ali of?ne reql�ired inforrnation rnay
<br /> result in a delay af processing your application. 5ubm{t this application, a compiete copy of the
<br /> site evaluation and the design at least 3 working days prior to the projected instailation date.
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<br /> Property Owner_ ���1 ti► �C � ��'�,� r,'�: �� r'�,�Z'iyc�� �,_-------Email:
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<br /> Mailing_Address: _33Z. Z Kt� S f��,t�+_ _�.���� i`�i c� . �';"!�� -�'L�---_-
<br /> F�none: Celi: i;;� �� � •;�;�• Work: Home:
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<br /> Desi�ner: %,° -,� ���� C (.`>�►� License# s i� Email: - ---- Phone: ,'t,-�; y�lu �';
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<br /> Instafler/Cantractor: �}�,,,;��� �icense#�= �Ema�l: :v� "'FShone: ;i, � �iz y_����
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<br /> Date to be Installed: _ �(; j 7 J�_____ _ ` I
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<br /> Propert�Address: _ �I'-� � Y�ti� � � t��i. :: ' r �:.��� , __c' �-�! '` '----- - -
<br /> Existin Se t�c S stem E es: Yes Nd Com liance Ins ection Date: i
<br /> ParCei: (ifnaaddressi �
<br /> General Lot Dimensions: Width: _ _ De tp h: _ Total Area: r,4cres or sq�r�
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<br /> Home TyPe_�'_� :�l �. s #of Bedrooms: �> C{othes Washer: ! Water Cond: � �
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<br /> ,_Garba�e Disposa%__.____ Hot TubiWhir aol:__________Dishwasher� ,�
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<br /> � Well: Existing New;r6 h���,sr�ue�� Size of Casing:�; Dep#h of Casin : � ' �
<br /> PROPOSED SEPI'IC INFORMAI'IQN
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<br /> j Soi! Types. ' ti ,.�<t Sizing Factor: _ b 0 -------- �'
<br /> j Septic: New Replacement � Addition Othe��
<br /> � Tanks: Qty: � New .� Existing Totaf
<br /> � Tank Type =����_�'�::r��. Capacity _ �,.._,�:_ _ Manufacturer ���}; , ,' w � .::y,r,?
<br /> , Pump Station: Tank Type �•_���,t�_Capacity i ��.., Manufacturer �'�,._���;���� !�>,':� r�°
<br /> � (if appl�cab/ej Pump 5ize Type Failure Alarm Type_ ,
<br /> � Drainfield Totat Length Total Width � Maximum Depth
<br /> ; Trenches wlrock Trench w/lchambers
<br /> j Rock below pipe in �
<br /> i Pressure Bed Mound Other (explain}
<br /> i Maunci Dimensions: Rock Bed x ,: '� ft Absorption Area � x v�1 ft
<br /> I Ciean Fil! below rock bed , `�? inches
<br /> j Fitter: Type Manufacturer Alarm Type:
<br /> LNew designs shall adhere to 2008 MPCA standards.
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<br /> , OFFICE USE ONLY r ��
<br /> ; Permit#���-D 1 �8 ? Payment Rec'd Zonirig District Y ,
<br /> ! Field Checked Date inspected� New/Repiace
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