Gertens permit applicationAPPLICATION FOR SEPTIC PERMIT
Inspectron, Inc.
15120 Chippendale Ave. Suite 202
Rosemount, MN 55068
Phone: 651-322-6626 or 800-322-6153
Fax: 651-322-7580
Please print all information
Permit #
Date Received:
Property Owner Narne: r -.n •J
(Last Name, First Name) ],
Address: �-1v-�5 A,, Q- , - (, -1L-
(Street or Box, City, State, Zip Code)
Site Address: 10!5 Y" '-c_- L' . d 1e- XU'0'
City or Township: IE- ONri0.n rV.,N Property Identification Number(PIN)
U
COPY OF SITE EVALUATION AND SYSTEM DESIGN MUST BE ATTACHED
Designer:
Name Address Telephone State License #
Installer:
Name Address Telephone State License #
SYSTEM INFORMATION
Buildinq Use
Type of System
Building Information
❑Residential
❑ Type I Standard
_Number of Bedrooms
RNon-Residentialj
LType II Holding Tank
Future Bedrooms
❑Type III Chamber orSB2 Pipe
_Solids Grinder/Bsmt
Type of Improvement
❑Type IV Advanced
_Garbage Disposal
F1 New System
❑Type V Permormance
_ Dishwasher
❑Replacement System
❑Alteration or Repair of Existing System
❑Abandonment
❑Tank Replacement Only
System Gallons per day
System Type
Number of New Tanks Installed
Trench/Rock
Trench/Chamber
Number of Existing Tanks
Pressure Beds
Mound
Total Number of Tanks
At Grade
Trench/EZ Flow
REQUIRED SETBACKS - Check all that
apply Septic Tank
Drainfield
Property Lines
1-110 Feet
010 Feet
Occupied Building
010 Feet
❑20 Feet
Recreation Lake or Tributary Creek
075 Feet
075 Feet
All Other Shorelands
❑150 Feet
Ell 50 Feet
Buried Pressure Distribution Water Pipes
El 10 Feet
❑10 Feet
Well (50 + of casting or 10' of impervious material) ❑50 Feet
050 Feet
Well (not meeting above specifications)
❑50 Feet
Ell 00 Feet