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l CTTY OF ELK RIVrR <br />P.O. Box 490 • Elk River, MN 55330 • (763) 441-4900 <br />_ocation of job <br />owner I'Y1r 7ya 1 rL� Address <br />.icensed Designer ba N) Q P Fri License # cJ l <br />+ ' hL License # <br />,icensed Installers ' � - • ►� <br />signature Date R- c26 — v"1 <br />(Show location of house, tank, drainfield, property line and well) <br />N <br />W ® R <br />1 <br />Ch a� <br />c <br />c7.h <br />GAS T'a•�CS/h/� t.4!+?1� <br />I � <br />q32 Y-oZ <br />• V <br />NOTE: On ALL replacements and additions, tanks must be exposed for baffle inspection. <br />COMMENTS: <br />New Work ❑ Outside Lift <br />Replacement M Ejector ❑ <br />Addition ❑ Gravity ❑ <br />Mound System ❑ <br />Tank Size <br />I'Zcta C-i <br />Tank Size <br />At1 <br />Square Footage of Drainfield Area <br />2 <br />Deipth of Rock Under Pie <br />Depth of Rock Over <br />-Pipe <br />Graveless <br />Depth of Dirt Cover <br />Number of Bedrooms <br />DATE <br />INSPECTOR <br />COMMENTS <br />-eaas, -?"I'7 <br />V U+O SOl <br />THIS FORM MUST BE FILLED OUT BY A LICENSED INSTALLER (ASBUILT) <br />(i) CTTY COPY. (2) OWNER COPY, (3) LICENSED INSTALLER COPY <br />