Laserfiche WebLink
Property address: 4760 Bayside_ Rd <br />City: Maple Plaine State: MN <br />5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) <br />Tank #1: ❑ Yes ® No Verification method used: <br />Tank #2: ❑ Yes ® No Verification method used: <br />6. Is there evidence of the followina? <br />Parcel ID: <br />Zip code: 55359 <br />Tank (check if resent) <br />Tank teaks below the <br />designed operating depth <br />Tank leaks above the <br />designed operating depth <br />Maintenance hole cover is <br />damaged, cracked, unsecured, or <br />appears to be structurally unsound <br />® Septic/holdingSeptic/holding Tank #1 <br />❑ Yes <br />® No <br />❑ Yes <br />® No <br />❑ Yes ® No <br />® Septic/holdingSeptic/holding Tank #2 <br />❑ Yes <br />® No <br />❑ Yes <br />®No <br />❑ Yes ® No <br />❑ Pretreatment Tank <br />❑ Yes <br />❑ No <br />❑ Yes <br />[-]No <br />❑ Yes ❑ No <br />® Pump Tank <br />❑ Yes <br />® No <br />❑ Yes <br />® No <br />❑ Yes ® No <br />Describe detail for any "Yes" <br />7. How many gallons of septage were removed? <br />Tank #1: 1000 - Tank #2: 1000 Pretreatment Tank: Pump Tank: 500 <br />8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other <br />Explanation (Facility name/Site #): Blue Lake <br />9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? <br />❑ Yes ® No If yes, identify tank and explain: <br />❑ Evidence of non -domestic waste ❑ Baffle(s) condition ❑ Effluent screen condition <br />❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.) <br />Explanation: <br />10. List any troubleshooting and minor repairs completed or declined by owner: <br />❑ Troubleshooting and repairs conducted: ❑ Repairs declined by owner: <br />Additional comments or suggestions for owners consideration: <br />Pumping record <br />1 personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance <br />with Minnesota Rules Chapters 7080 — 7083: <br />® As a noncertified individual who has received proper training, daily work review, and periodic observation, or <br />❑ As a designated certified individual of the business listed below. <br />By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that <br />this information can be used for the purpose of processing this form. <br />Company information <br />Company name: Mike's Septic & McKinley Sewer <br />Business license number: L 1665 & L2899 <br />Email: <br />Employee's signature: Cody McKinley <br />Employee information <br />Print name: Cody McKinley <br />Certification number: (if applicable): <br />Phone number: 952-440-1800 <br />Date (mm/dd/yyyy): 2/25/2025 <br />www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats <br />wq-wwists4-38 • 4128121 Page 2 of 3 <br />