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OSTP As-Built Form <br />Owner:________________________________Parcel Number: ______________________ <br />Street/City/Zip Code:_________________________________________________________________________ <br />Lot: ___________ Section: ___________ Township: ____________ N Range: ____________ W <br />Installation Date:_______________ Installer:__________________________ License Number: __________ <br />Is the system in Shoreland, serving a MDH facility or in a Wellhead Protection area? YES NO <br />Number of Bedrooms/ Flow Rate:_________________# / gpd Septic Tanks, No & Size:______________#/gal <br />Pump Tank Size:_________________gal Tank Manufacturer: __________________________________ <br />Pump Size: _________ hp _______ gpm _______ft of TDH Floats properly set? YES NO <br />Soil Treatment Area: <br />TYPE I TYPE II TYPE III TYPE IV TYPE V <br />TRENCH BED MOUND AT-GRADE WARRANTIED OTHER:______________ <br />Limiting Layer/Depth:________” <br />Depth from Surface:_________ ” <br />Media or Slat depth:__________ ” <br />Trench Width:______________ft <br />Rockbed Size:_____________________ <br />Adsorption Width:__________________ <br />Sand Depth:_______________________ <br />(under mound) <br />Describe: __________________ <br />__________________________ <br />__________________________ <br />__________________________ <br />Bottom Square Feet Area:____ft 2 <br />Design Variances:____________________________________________________________________________ <br /> <br />Other Information: <br />List any further system descriptions: <br /> <br /> <br />List any material testing results (jar test, sieve analysis, etc): <br /> <br /> <br /> <br />List conditions during construction: <br /> <br /> <br /> <br />List who is responsible for establishing vegetative cover: <br /> <br /> <br />I hereby certify that I have completed this work in accordance with applicable ordinances, rules, and laws. <br />________________________________________(Installer) ________________(license #) ___________(Date) <br />Custom One Homes 0411723420021 <br />2700 White Oak Circle, Orono, MN 55356 <br />Saint Croix Sewer <br />5 / 750 2 / 1,500 & 1,000 <br />1000 WIESER CONCRETE <br />0.4 36 16.1 <br />n <br />12 10' <br />20' <br />6"24" <br />Rock <br />625 <br />4