HomeMy WebLinkAbout07/22/2020 septic complianceJin, Eicher
Septic Service, LLC
1205 LaBeaux Ave NE
St. Michael , MN 55376
DATE 1 -Z. ·I-'Zti>Z..:,
Pumping Fee: 1.5 '-/o _ P-l.:7
Long Pull Fee :
Other Repairs:
\"'J\.lc:.. ~--~~_A.-:11\
Total Cost of Ser\iice :
12 ~-chJ
00
~~I(, y~
Maintenance Inspection Form
MPCA Uc. # 654
Maintainer
• Phone : 763-497-2764
~Nick
• Email: d_uaneseptic@centurylink.net
INVOICE
Nam~ r . ...._ . \w...11 __ +~0" -:r-<t 0 V\.
Addre4s : · { -J,--.h. l '2. O i::-~'"'-Cr-o..k'
City/Statf ip:·
l,.,-A-°"Z"t.-.J-._
Payment Method: D Check D Cash Credit
;· I ,, ' • ., • ¥ ,.. ~-,.
Mainten ance hole·cover is damaged, Tank (check· if preseni) 1· ~f•3 Tank leaks below th e . Tank leaks ·above the ,i ·~ ,;,",-cr ac ked, unsecured, or appears to be ' . ,.
iHi if' ll-_..i.,,_· • designed operati ng depth designed operating de ptfi ' .. , .. , " ~-stru ctur allv unsou nd
O'"Seplic/holding Tank #1
D Yes D Yes D Yes Gallons:1st,-e>
EJ..S'eptic/holding Tank #2
D Yes D Yes D Yes Gallons: l (51;nO
D Pretreatment Tank
Gallons: D Yes D No D Yes D No D Yes D No
~mp Tank
D Yes D Yes D Yes ~o Gallons: J ',"I.TO
How Accessed : aintenance Hole Scum/Sludge Measured Maintenance Holes Securely Replaced: Reason For Pumping:
D Other (see attached) D Yes D-1es D No --~
_s;rac e ans, missing a es, ro en cover: , e c .. so, exp a n ,n commen s eow.
Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system, i.e.,
k d t k . . b ff/ b k s t ' If I I . t b I
Tank #1 D Yes li'.'.r No Tank #2 D Yes ~o Pump Tank D Yes ~o System
Structural integrity Structural integrity Structural integrity ~ound Risers leaking D Risers leaking Risers leaking Elevated drainfield D Baffles Baffles Baffles Pressure bed Non-domestic waste D Non-domestic waste Electrical issues D Trenches
Non-domestic waste Ponding/Surfacing
D Effluent Filter/screen Other:
Cleaned? D Yes No
/Comments:
Disposal: Land Application: Wastewater Treatment Plant
Disposal Site : I Lime: Gallons Plowed: Yes No
Time: Temperature: pH : >12 D
Time : Temperature: pH: >12 D
Parcel ID: ______ _
Zip code : __,,""')S~S>LJ.91-/--
_Qptf on al section: Sewage Tank Com pliance Ce rti ffcatf on
This form does not represent a complete system lnep ecli on report and only certifies sewag e ta nk compliance status.
lns~ctlons: This sect ion of the form may be com ple ted and signed by a Designated Certified Individual (DCI) of a licensed SSTS
Maintenance Business who personally c_ondu cts the necessary procedure s to assess th e compliance status of each sewage tank in the system.
When this section of the form Is signed by a qualifi ed ce rt ifie d profess ional , it becomes necessary supporting documentation to an
Existing System Compliance Inspection Report: Complian ce in spection form -Existing system (wq-wwists4-31bl. This form can be
found on the MPCA website at https :1/www ,pca.state.m n.us/wate r/ssts-and -msts-tec hnical-an d-co mpliance-criteria .
The information and certified statement on this form is required wh en ex isting septic tank compliance status is determined by an
individual other than the SSTS Inspector that submits the inspection repo rt. It represe nts a third party assessment of SSTS
component compliance and is allowable under Minn . R. 7082.0700 , subp . 4 Item (B ) subitem (1 ). This form is valid for a period of
three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is
required according to local regulations. Addltlonal Administrative Rule references for this activity can be found at Minn .
R. 7082 .0700, subp. 4 Items B, C, and D; 7083.0730 Item C.
Affirm ~ree statements :
· ~rtificate ·of sewage tank compliance·-· ···---········ · ..... ot'sewage tank non-compliance -· ·---------·--;
· Select all that apply: (
!2rThe SSTS does not contain a seepage pit, cesspool,
_ <!!YWell, leaching pit, or other pit.
Jd1t does not contain a sewage tank that was designed
to be watertight, but subsequently leaks below the
· _,..deSigned operating depth.
,EJ It does not represent an imminent safety threat by
reason of unsecured, damaged, or weak
D The SSTS has a seepage pit, cesspool, drywell,
leaching pit, or other pit. D It has a sewage tank that was designed to be
watertight , but subsequently leaks below the designed
operating depth.
0 It presents a threat to public safety by reason of
" ... _._mai11te~~~~ hole _ cover(s) or other unsafe condition .... ) .....
unsecured, damaged, or weak maintenance hole
-· cove~(s) or other unsafe condition . ------·-.. ·-·-· ·-
Company information Designated Certified Individual (DCI) information
Company name: Duane's Septic Service Print name: JI /h Gd~
Business license number: 654 Certification number: C2084
I personally conducted the work described above as a Designated Certified Individual of a Minnesota-licensed SSTS Maintenance
Business. I personally conducted the n essary procedures to assess the compliance status of each sewage tank in this SSTS:
Designated Certified
Individual's signature: __ .::__-lrJ.LiL-\:,q,.__,,c;.. ____ Date (mm/dd/yyyy): __ 0~7-1-/_J._/ -1-1-~c....O_d-_O __
I I
lrffM.pca..state .mn.us • 651 -296-6300 • 800 ·657-3864 Use your preferred relay service , Available In alternative forma ts
~JI • f/27 lt7 Page 3 of 3