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