Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />System discharges sewage to the ❑ Yes' ® No <br />ground surface <br />System discharges sewage to drain ❑ Yes' E No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes' ❑ No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is an <br />imminent threat to public health and safety, <br />Describe verification methods and results: <br />Searched area <br />Attached supporting documentation: <br />❑ Other: <br />ED Not applicable <br />2. Tank integrity — Compliance component #2 of 5 <br />Compliance criteria: <br />System consists of a seepage pit, <br />cesspool, drywell, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their <br />designed operating depth? <br />Yes" ® No <br />❑ Yes' ® No <br />If yes, which sewage tank(s) leaks: <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater, <br />Attached supporting documentation: <br />❑ Pumped at time of inspection <br />Name of maintenance business: <br />License number of maintenance business: <br />Date of maintenance: <br />❑ Existing tank integrity assessment (Attach) <br />Date of maintenance <br />(mmidd/yyyy): (must be within three years) <br />(See form instructions to ensure assessment complies with <br />Minn. R. 7082.0700 subp. 4 8 (?)) <br />❑ Tank is Noncompliant (pumping not necessary - explain below) <br />❑ Other: <br />Describe verification methods and results: <br />The tanks were pmped and certified by Elmer J. Peterson Company. See attached report. <br />https://www.pca.state.mn,us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwfsts4-31b • 1111/21 Poge 2 of 4 <br />