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C"TTY OF ELK RIVrR <br />P.O. Box 490 • Elk River, MN 55330 • (763) 441-4900 <br />.ocation of job 11-1 H'(-1 IITL t+v Nl&z All <br />owner 11''1 -Ar 1►A Address <br />,icensed Designer K�r License # t <br />+ +ll- License # Cr�� <br />.icensed Installer - C i _ <br />Date 8 - c?Ci —y <br />>ignature <br />(Show location of house, tank, drainfield, property line and well) <br />N <br />I <br />s <br />l .. <br />v.h <br />30 <br />al�h <br />r <br />114. o,S/ m7ril <br />I° ' : N .c.------ <br />'V <br />Ire <br />NOTE: On ALL replacements and additions, tanks must be exposed for baffle inspection. <br />COMMENTS: <br />New Work ❑ Outside Lift 21 <br />Replacement M Ejector ❑ <br />Addition ❑ Gravity ❑ <br />Mound System ❑ <br />Tank Size <br />�zo'' tki <br />Tank Size <br />K�1 <br />Square Footage of Drainfield Area <br />Z <br />De th of Rock Under Pie <br />De th of Rock Over Pie <br />Graveless <br />De th of Dirt Cover <br />Number of Bedrooms <br />DATE�Q- <br />INSPECTOR— <br />COMMENTS <br />+►h-2 asf <br />71�3'1J <br />THIS FORM MUST BE FILLED OUT BY A LICENSED INSTALLER (ASBUILT) <br />(1) CITY COPY, (2) OWNER COPY, (3) LICENSED INSTALLER COPY <br />