Laserfiche WebLink
Rug�08 ,48 Ul : lZp Rndy Kleindl (9521 -442-9281 p. 4 <br /> Parcel numb r: System status: �Compliant ❑ Noncompliant <br /> (as detem►ined by this form) <br /> Tank In grity and Safety Compliance <br /> Complia ce 15sue #2 of 4 <br /> Date of obs rvation: _ � �O Reason for observation: Q'GJ Yl� ���� . _.. ..— <br /> This form e ires on (three years): — <br /> Complian e questionslcriteria: (Required) Verification Method*": (Optional) <br /> _ Check he appropriate box (Check the appropriafe box) <br /> Does the sy tem consist of a seepage pit', ❑Yes �No ❑ Probed tank bottom <br /> cess�ool,d ell,or leaching pit? _ ❑ Observed low liquid level <br /> Do any sew ge tank(s) leak below their ❑Yes (�No <br /> desi ned o ratin de th? ❑ Examined construction records <br /> If yes, identi which sewage �'�amined empty(pumped)tank <br /> tank leaks. •- ❑ Probed outside tank for"black soil" <br /> Any"yes"a swer indicates thaf the system is failing to protecf � pressure/vacuum check <br /> ground wat r. <br /> ❑ Other: <br /> ' Seepage its meeting 7080.2550 may be compliant if allowed <br /> in ordina e by local pennitting authority. <br /> "No standard protocol exists. Thrs/ist is not exhaustive,in <br /> sequentia!order, nor does it indicafe whlch combinations <br /> are necessary to make this determination. <br /> Safety C eck <br /> 1. Are an maintenance hole covers damaged, cracked, or appeared ta be structura{ly unsound? ❑ Yes" �No <br /> 2. Were a I maintenance hole covers replaced in a secured manner(e.g.,all screws replaced)? (�Yes ❑ No' <br /> 3. Was s ondary access restraint present(safety pan,second cover, or safety netting)—highly recommended. ❑Yes �No <br /> 4. Was a y other safety/health issue present? ❑Yes' (�No <br /> Explain ___ �. — - — <br /> *Syste is an imminent threat fo public hea/th and safeiy. <br /> Certific tion <br /> This form i to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance <br /> Inspection Form for Existing Subsurface Sewage Treatrnent Systems. Observations,interpretations,and conGusions must be <br /> completed y an inspector, maintainer, or service provider.Completed form must be submitted to the local unit of govemment within <br /> 15 days. <br /> Property o ner narne(s): Dean Patterson _ _— — —� —� -- <br /> Property a dress: 2058 Shoreline Drive __— -•— �— — �— —�- <br /> Property o ners address(ifdifferent): — -- <br /> County, Hennepin Phone: 612-328-1173 _ — <br /> I hereby c ify fhat!personally made the observatrons,interpretations, and conc/usions repo�ted on this form and that they ane <br /> correcf. <br /> Name: ndrew Kleindl CeRification number: 2926 . _ <br /> Business li ense name and number: Jim's Excavatin , LLC _� __ _.._ or <br /> Name of I I unit of govemment: '— <br /> Signature: Date: ���_. _ <br /> ,.,,,_��r -3� Comptiance Inspection Form forExistrng SSTS <br />