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UNIVERSITY <br />OF MINNESOTA OTQ As -Built Form <br />Owner: El/e'" rci!e-r- Parcel Number: O',i 4 01 <br />Street/City/Zip Code: 1-17,'V ✓'ems , � azw <br />Lot: Section: Township: N Range: W <br />Installation Date: 9ti1 3A ( Installer: uM � �''' License Number: 0 <br />is the system in Shoreland, serving a MDH facility or in a Wellhead Protection area? ❑ f YES NO <br />� cv <br />Number of Bedrooms/ Flow Rate:—3 50 # / gpd Septic Tanks, No & Size: i V #/gal <br />Pump Tank Size: <br />?s 7 gal Tank Manufacturer:3t^�J.7 <br />Pump Size: '�� hp 7 gpm �-)5 ft of TDH Floats properly set? 4 YES ❑ NO <br />Soil Treatment Area: <br />❑ TYPE I ❑ TYPE 11 ❑ TYPE III &f TYPE IV ❑ TYPE V <br />❑ TRENCH ❑ BED Of MOUND ❑ AT -GRADE ❑ WARRANTIED ❑ OTHER: <br />Limiting Layer/Depth: Rockbed Size: /0 x ' , Describe: <br />y <br />Depth from Surface: Adsorption Width: <br />Media or Slat depth: Sand Depth: la hu' o <br />(under mound) <br />Trench Width: ft <br />Bottom Square Feet Area:ft r <br />Design Variances: <br />Other Information: <br />List any further system descriptions: <br />List any material testing results (jar test, sieve analysis, etc): <br />S � , Ibos It&C 4d <br />List conditions during construction: <br />740 t -_ qo'< <br />List who is responsible for establishing vegetative cover: <br />5 Aq i¢ <br />I herebv certify that I have completed this work in accordance with applicable ordinances, rules, and laws. <br />Installer) // !' f (license#) �- (Date) <br />