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request.pdf https://word-view.off3ceapps.live.com/wv/WordViewer/request.pdf?F...
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<br /> ° HENNES SEPTi� PUMFfNG �OR OF�CE:;s�OR��'
<br /> ` 2237 ValBey�liew Rd �
<br /> �� Sltako�pee, MN 55379 � u��i�'�£�
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<br /> � �e��xc T�nk _Pumping Ce�°t��c��� ���.tP� --- --- ;
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<br /> U�arnef �iam� _ _ .___ _ _ _ _ - ---- i3�te of pumping--�-_-��. __
<br /> , , . ., . , ; .. : �-Tra�sfer of�roperty
<br /> Proj�ct Acidress `"; ' . ' '-� � � . � ;" : _f----v � P.outine Pu�pin�
<br /> '! �istina tank-new system
<br /> Septic Tank Siae: gallons Inlet Baffle;� , i j Hoiding tank
<br /> ��arn�artments� �� One �� Tv+,o t�iareriai __.� 1==`"`` =- %;larr� pres�rt _ _
<br /> 5�p�ic Tank Constre+ctior�: intact� ��Yes ❑ No IF SYS�'E�►f INC�UD�S
<br /> �:"Concrete �teplac2�i? � Yes ❑ No MClRE's'�l�N fllVE T�NK,
<br /> ❑ Fiberg{ass Cltitlet Baf�le.� CO�+�IPL�`T'��"NIS S��L'TION
<br /> !i Plastic Vateriai �.._ �i'--_`_`__` �O�R E�►�i� A�i�;�il�t�Ai.
<br /> � Metai ir:iaci% �Yes ❑ No �Af�K £�N A �E�ARATE
<br /> � Ottjer _ -_. ---__ Rep{ac�? J Yes � No P�lMPIldC �E�t��.�.Cl���
<br /> ;,�,-�,,._ F€?RM :4l�i? �?TArH.
<br /> Se�at�ge r�cnt��ed �_ � , 4ailons U Additiona! tank(s)
<br /> l���i� +�sn �hro� h: ;- - _ --------- __------__.—�—___--_.�_._-------
<br /> � � � i ;t�;;;;anta Ru1�s;Q9apter 7CSi;.f1?TSSuL�.3.C. I°�e osmner C;oivrter's a,gent refusK:s tv allow. the;�mesat �
<br /> �i�IdlCli�Tlat1C� cICCeSS ! tJrrouyh a maintenaiKe hole,the l�censed purnper�twsi obidin a sryi�ecl.itetenrenl iruitl U�owner��owner`s �
<br /> ri '�'i 15�3'c'�LVOr pl}�3£ aqent that ltre cemer or aaenF w,as inf.�xmer:ofCt�rrPCt remnva�Prnrcx+ures and the r�s�n h�r relusal." �
<br /> *Reasan l�t�r�u€��a�r�g througi� inspection pipe:
<br /> *Komeowner sic�nature-rr'pumped througn inspec.�tion pipe:-- —__--`-------_--_-_.-
<br /> �a3ii"3�et3��Ce Ac��''S P�C�Se�tt? �] NG �j Y�s
<br /> Diam�ter of maintenanc� access: ' � inches at least dimension (must �?e 2Q"ta be �art of �ev� system)
<br /> �►ccess within 12"Qf ground surface"� Risers (r exisrin9�acidee�: inS�3e+Ctid�t �pipeS pr�S�tlt?
<br /> �±Yes - Iniet % Outlet I C:enter ,��.Conc�ete �' ',es - �r� iniet J Outiet J Center
<br /> [� No ,--,=�-' � � Plasiic ❑ tvc
<br /> ❑ Added ta: Inlet / C�.�*let/ Cen�er � Nane ❑ Added in,/ft.
<br /> to iniet! �ut�et ! Center
<br /> T�e septic tank j,�l70ES J ❑ Dt�ES 1�aT a��rear waiertight as of today`s da�te.
<br /> Tank iea(�age observed iseiow o�erating depth2 ❑ 1'es ��No
<br /> Ta�k ieakage a�t�served �bove o�eratinc� �ie�tl�? ❑ Yes �No
<br /> �ny drair.bacK from soil tre�tment are� ncat�Ge�!? L, Yes �No
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<br /> C��spasai met�toti: ��_Nlunicipal �reatmer�t _ _�,t.:_;•.,�- �; _, l
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<br /> �] i.and applicatior,
<br /> � � �ll l��
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<br /> Comme�ts���servation of any non-compiiance[re�nairs: ________
<br /> 1 _._ >._ , i . s,' � `tit � �— �+�!' fk i�`�
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<br /> 1 ne�eby cerbfv wi�i n�v sronanire as a lVlivi-licenseo FiimUer tnat my ob.servanons rerurdeo on thls tor�n a�e acru�ate to the hesc uf my p�oies�runal
<br /> knn�v/er/ge.as of Ghe date s�gnee fcr ttre pro,�e�fy stat�d aboe e. No determrn,�tion of future�rfnrmanre ca.n he made due tn unknown c'orxfitinrxs nfch
<br /> as abuse o(the syste;;,rr,u/or i,�ac'��;uaie:�;ainrcna�xe, ot whic/�riil!Jes�er�:rly:�ffec.t�e life of t7=sy�cc-,. _
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<br /> 4'um{�er n�me(PieasB^rintl 5tatr iicFncA ni.imhr�r Date --.
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<br /> Rim�signahire � Company Fnone number
<br /> Please subm�i�is record to th�homec��✓�_e.r ant�local unit o�ovemment wrthin 30_day_s__of�ur.�pin�,!��spection,_
<br /> 2 of 7 3/25/2013 6:12 Pr'
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