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HomeMy WebLinkAboutSeptic As BuiltUNIVERSITY OSTP As -Built Form OF MINNESOTA Owner: `% IV We, � b -42- Parcel Number: ti /� � �' 3 •�-�®� Street/City/Zip Code: `=e 7 iie-' /l/c',%LL AP'j-M Z2)= Lot: Section: Township: N Range: W Installation Date: 'S --- 17 " 1e5> Installer:9La,� License Number: Is the system in Shoreland, serving a MDH facility or in a We(head Protection area? ❑ YES ❑ NO Number of Bedrooms/ Flow Rate: # / gpd Septic Tanks, No & Size: #/gal G Pump Tank Size: A:" gal Tank Manufacturer: � � c:��'j Model # /X50 76'0 Date of Manufacture: 52-©10 Maximum Burial Depth: Pump Size: hp gpm ft of TDH Floats properly set? ❑ YES ❑ NO Soil Treatment Area: ❑ TYPE I ❑ TYPE II ❑ TYPE III ❑ TYPE IV ❑ TYPE V ❑ TRENCH ❑ BED if MOUND ❑ AT GRADE❑ WARRANTIED Limiting Layer/Depth: Rockbed Size: Depth from Surface: " Adsorption width: Rock or Slat depth: Sand depth:_ Diameter of Gravelless: (under mound) Trench Width: ft Bottom Square Feet Area: ft2 Design Variances: Site Drawing: p1, 9-3 North 143 �- 4,13 0 Describe: Items to be Identified: 1. Septic, holding and pump tanks, piping, and soil system configuration. Label bed or trench width and length or rockbed size, absorption width and final dimensions. Indicate alarm location. 2. Show all setbacks from tank and soil system a. Property boundries b. Buildings c. Wells d. Water bodies e. Road right-of-way 3. Improvements - present and future. 4. Benchmark location and distance of tank and soil system from benchmark 5. Replacement site 6. Abandoned system Reverse Side