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Apr 20 1506:17p Joseph Olson 763-498-8290 p.12 <br /> Apr. 17 .2'015 08:56 AM Duane's Septic Service 7634972764 PAGE. 1/ 1 <br /> , <br /> Parcel number: . System status: Comp1Ient 0 Noncompliant, ' <br /> (es detemrine h! <br /> 1 05i7,7170P <br /> Tank Integrity end Safety Compliance . ,4-.`,'Michltal, M[i11 <br /> . Compliance Issue#2 of 4 ' - . - <br /> • , <br /> Date of observation: Li- (Li-15- <br /> Reason for observation: , . =See 1113 ,1 _ . <br /> d! <br /> This form expires on(three years): -(L- I • J <br /> • <br /> Compliance questlonislcriteria: (Required) - Verification Method `:(Optional) _ <br /> JGheck the appropriate box) • (Check the appropriate bilk) <br /> Does the syetern consiatof a•seepage pit`, 0 Yes i ao [alrobed tank botton'i <br /> cesspool,drywall,or leaching pit? • • <br /> Do any sewage tank(a)leak below their -0 Yes LiNo 0 4bsenled low liquid level <br /> designed operating depth? 0/•Examined construction records . - <br /> If yes,Identify which sewage ill Examined empty. (Pumped)tank • <br /> tank leeks. <br /> • Any"yes"answer Indicates that the system fa felling to protect ❑ Proud outside tank br'black loll' <br /> ground water, ❑ Pressure/vacuum-check _ <br /> ' Seepage pits meeting 70862550 rngy be compliant If allowed ❑ Other: <br /> in ordinance by.lacal permitting authority. • <br /> • <br /> No standard protocol exists. This list/s,not exhaustivo,kr <br /> sequential order, nor does It Indicate which combinations ' ' <br /> arra <br /> nee y to inaka.thla determinstlon; <br /> • <br /> "Safety Check - <br /> 1. Are any maintenance hole covers damaged,cracked, or appeared to be structurally unsound? ❑❑Ver. 2No•• ` <br /> •2. Were all maintenance hole covers replaced In a secured manner(e:g.;afl-saews replaced)? idYes 0 No•.' <br /> 3. " Was secondary access restraint present(safety pen,second cover,or safely netting)-highly recommended. ❑Yes tom,Ivo <br /> 4. Was any other eafelylhealth isaue present? • _ ❑Yes" .12". 6- <br /> • Explain: • . <br /> 'System Is en Imminent threat to pOb/M health and safety. . . A • • <br /> Certification . <br /> This form is to be completed and attached to the Summary Form of.the Mlnneevta Pollution Control Agency's(MPC/).Compliance • <br /> Inspection Form for Existing Subsurface Sewage•Trealnient Systems..Observatlons,Interpretations,and conclusions must be. . <br /> completed.by an inspector,maintainer,or service provider.Completed forth most be submitted to the local unit of government within <br /> 15 days. . <br /> Property owner name(s): ., <br /> Property address: .62 7S o 'ci a,tz... CI(1. • . . <br /> Property owners address(!f different): ' • . <br /> • County: Phone: : . . <br /> • <br /> 1 hereby certify that(personally made the observations, Interpretations, end conclusions reported an this form.end that they are <br /> COtrect. <br /> • <br /> Name: ___%.7-/4 Eich,--c .- • Certification number a C),? /- <br /> (l <br /> Businesa license name end number: Li if2e. �•P ski �i9 r Vor <br /> ilma LI. 1.- .- . ' <br /> Name of local un ovemment: • . . • <br /> Signature; iDale: LI-/'-(-/.,,5• ' <br /> wq-wwfsts4'31 . • Compliance Inspection Form for Ekfsting SSTS <br /> • <br /> A ti 1110 <br />