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Septic Service, LLC <br />1205 LaBeaux Ave NE <br />St. Michael, MN 55376 <br />DATE q- 2G-z4 <br />Maintenance Inspection Form <br />MPCA Lic. #L4286 <br />Maintainer = Jim <br />'Nick <br />0 Sam <br />• Phone: 763-497-2764 <br />• Email: duaneseptic@centurylink.net <br />Pumping Fee: <br />_j z -,S'--3 <br />Name: <br />50A.0 kA <br />IIY V VI%,L. <br />Long Pull Fee: <br />Address: <br />Other Repairs: <br />City/State/Zip: <br />Total Cost of Service: <br />Payment Method: <br />Check ❑ Cash <br />❑ Credit <br />�S 7. <br />SQ <br />73 <br />$S-s% 50 <br />ou <br />Tank (check if present) <br />Tank leaks below the <br />Tank leaks above the <br />Maintenance hole cover is damaged, <br />cracked, unsecured, or appears to be <br />designed operating depth <br />designed operating depth <br />structurall <br />unsound <br />��� <br />u'Septic/holding Tank #1 <br />Gallons:[ e,,L-> <br />❑ Yes to <br />❑ Yes <br />0- o <br />❑ Yes <br />Er -No <br />Septic/holding Tank #2 <br />Gallons: �a,3,� <br />❑ Yes E� o <br />❑ Yes <br />❑'No <br />❑ Yes <br />❑�o <br />❑ Pretreatment Tank <br />Gallons: <br />❑ Yes ❑ No <br />❑ Yes <br />❑ No <br />❑ Yes <br />❑ No <br />❑ Pump Tank <br />Gallons: <br />El ElNo <br />ElYes <br />ElNo <br />ElYes <br />❑ No <br />How Accessed: P119 aintenance Hole <br />Scum/Sludge Measured <br />Maintenance Holes Securely Replaced: <br />Reason For Pumping: <br />El Other (see attached) <br />Yes ❑ No <br />Ett es ❑ No <br />.4 .i n <br />Did you identify any operational issues or unsafe conditions while assessing the sewage tanks In this system, i.e., <br />-cracked tanks. missino baffles. broken carders. etc 7 Tf sn. exnlain in rnmmanl-c ha/nw <br />Tank #1 ❑ Yes ZNo <br />Tank #2 ❑ Yes o <br />Pump Tank ❑ Yes ❑ No <br />System <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Structural integrity <br />❑ Mound <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Risers leaking <br />❑ Elevated drainfield <br />❑ Baffles <br />❑ Baffles <br />❑ Baffles <br />❑ Pressure bed <br />❑ Non -domestic waste <br />❑ Non -domestic waste <br />❑ Electrical issues <br />- enches <br />❑ Non -domestic waste <br />❑ Ponding/Surfacing <br />❑ Effluent Filter/screen <br />❑ Other: <br />Cleaned? ❑ Yes ❑ No <br />Comments: <br />Disposal: ❑ Land Application: ❑- astewater Treatment Plant <br />Disposal Site: <br />Lime: <br />Gallons ISM <br />Plowed: ❑ Yes ❑ No <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />Time: <br />Temperature: <br />pH: > 12 ❑ <br />��;,�,�,�A;-tea::.,,, �--�� <br />