Laserfiche WebLink
Jun 28 1103:51 p Elmer J.Peterson Co. 763-972-7217 p.2 <br /> Parcel number. System status: ®Compliant ❑Noncompliant <br /> (as determined by this form) <br /> Tank Integrity and Safety Compliance- Compliance Inspection Form for Existing SS TS <br /> Compliance Issue#2 of 4 <br /> Data of observation: 8127111 Reason for observation: Poiret of Sale <br /> This form expires on(three years): 8127114 <br /> Compliance questionslcriteria: (Required) Verification Method":(Optional) <br /> (Check the&Ayopriate box) (Check the appropriate box) <br /> Does the system consist of a seepage pit•, i ❑Yes ®No ❑ Probed tank bottom <br /> ceWcol,drywall,or leaching it? <br /> Do any sewage tank(s)leak below their ❑Yes ®No ❑ Observed low liquid levet <br /> designed operating depth? ❑ Examined construction records <br /> if yes,Identify which ® Examined empty(pumped)tank <br /> sewage tank leaks. <br /> Any-yes-amwerinc0cates*at Me system la iffng to protect C] Probed outside tank for <br /> f black soil" <br /> ground water. ❑ PressureMacuum deck <br /> ❑ <br /> • Seepage pits meeting 7080.2550 may be compliant if allowed Other: <br /> in ordinance by local permitting authority. <br /> No standard protocol exists. This list is not exhaustive,in <br /> sequential order.nor does It Indkete which combinations <br /> are necessary to make this deterrnlnatian. <br /> Safety Check <br /> 1. Are maintenance hole corers damaged,cracked,or appeared to be structurally unsound? ❑Yes• ® No <br /> 2. Were maintenance hole covers replaced in a secured manner(e.g.,screws replaced)? ®Yes ❑NO* <br /> 3. Was secondaryacoess restraint present(safety pen,second corer,or safely netting)-highly recommended. ❑Yesm,l]No <br /> 4. Are othersafetyfhealth Issue present? ❑Yes` ®No <br /> Explain: <br /> *System Is an Imminent threat to pubtic health anal safety. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(M PCA)Compliance <br /> inspection Form for Existing Subsurface Sewage Treatment Systems.Observations, interpretation,and conclusions must be <br /> completed by an Inspector, maintainer,or service provider.Completed form must be subn*ed to the Total unit of government within <br /> Iii days. <br /> Property owner name(s): John Tasted <br /> Property address: 210 North Shore Drive W Mound, MN 55384 _ <br /> Property owner's address(irdittarent): <br /> County. Hennepin Property owner phone: <br /> I hereby certify that t personally made the obserrat ns.fnierpref®tions,and conclusions reported on this form and het they ate <br /> correct. <br /> Name: James Braegelmann Certification number: <br /> Busi nese license name and number: Elmer J.Peterson Co. License#299 or <br /> Name oft P if"f government: <br /> Signature: Data 6127/11 <br /> www.pca.state.mn.us - 551-296-6300 - SM-657-3864 TTY 651-282.5332 cr 8[10-657-3964 Avaitable in alternative formats <br /> wq-wwrlsts4.31 • 4124109 Page 3 of 8 <br />