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�1 �y 9 <br />V <br />City of SEPTIC TANK <br />AND DRAINFIELD <br />Elk River PERMIT APPLICATION <br />PERMIT NOS. _D1 1-1 9 9 <br />Date 14 1 f <br />Site Address l �]s �y fi l klet ,, I'J (vim Suite/Unit No. <br />Tenant/Building Name Condominium No. <br />The Applicant is ❑ Owne [Contractor ❑ System Designer <br />Property Name <br />Owner Address <br />City t K &<AState ► yuy Zip Code 47�2c? Phone �L'{/- _ 40�2 5� <br />Contractor Name L--ye. = C4 "(' <br />Address Z�� c2 �'C 4tn- License # <br />City I r L-L State /it.&/ Zip Code 5 ,73o!' Phone � � �� i"S- <br />System Name _,1;U/r744-/ c Q,-y <br />s <br />Resigner Address t//doV It,14 /ram License # �© <br />City L L Gel u'f+2 State tq.,L• Zip CodeS:Le,&,_ Phone <br />Class of Work ❑ 1 New ❑ 2 Addition ❑ 3 Alteration/ [] Maintenance/Repair/ <br />Remodel Replace <br />0,000/ <br />Type of MY01 Single Family Residential ❑45 Recreational, Amusement <br />Structure ❑02 Single Family Connected to Single Family ❑46 Other Nonhousekeeping Shelter <br />❑03 Residential Garage 065 Industrial Buildings <br />❑30 Two Family Residential ❑70 Public Works and Utilities Building <br />031 Three -Four Family Residential 080 Public Schools <br />❑32 Multiple -Family Residential ❑81 Private Schools <br />❑40 Offices, Banks, Professional ❑85 Churches and Religious Buildings <br />❑41 Stores, Restaurants, Warehouse 088 Hospitals and Institutional Buildings <br />❑42 Hotels, Motels ❑93 Other Non -Residential Building <br />❑43 Parking Garage ❑95 Fences, Signs, antennas <br />044 Service Stations and Repair Garage 096 Other Nan -Building Structures <br />PLEASE COMPLETE OTHER SIDE <br />'lope, <br />d ICJ <br />13065 Orono parkway • PO. Box 490 • Elk River, MN 55330 • TDD & Phone: (612) 441-7420 • Fax: (612) 441-7425 <br />