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Home My WebLink About2017-00476 - backflow device/testing/repair • HMI 1111 111 CITY OF ORONO * 2750 KELLEY PARKWAY * 2 1 7 - 0 0 6 DATE ISSUED: 05/11 0/22 017 ORONO,MN 55356- (952) 249-4600 FAX: (952) 249-4616 ADDRESS : 550 OLD CRYSTAL BAY RD N PIN : 33-118-23-13-0021 LEGAL DESC : CRYSTAL BAY BUSINESS CENTER 2ND ADD : LOT 002 BLOCK 001 PERMIT TYPE : PLUMBING PROPERTY TYPE : COMMERCIAL-BUSINESS CONSTRUCTION TYPE : BACKFLOW DEVICE/TESTING/REPAIR NOTE: PERMIT FOR EXISTING BACKFLOW PREVENTORS AND REBUILDS ONLY APPLICANT BACKFLOW PREVENTER TESTING/REPAIR 10.00 STATE SURCHARGE FLAT-ADDITIONAL 1.00 CITY VIEW PLUMBING&HEATING MAIL-IN FEE 2.00 1880-B WAYZATA BLVD W P.O.BOX 150 TOTAL 13.00 LONG LAKE,MN 55356 Payment(s) (952)473-8793 CHECK 37022 13.00 Minnesota State License#:plbg-MB005208 OWNER JEM Tech 550 OLD CRYSTAL BAY RD N LONG LAKE,MN 55356- AGREEMENT AND SWORN STATEMENT The work for which this permit is issued shall be performed according to the approved plans and specifications,applicable City approvals,and the State Building Code. This permit is for only the work described and does not grant permission for additional or related work which requires separate permits. All provisions of laws and ordinances governing this type of work shall be compied with whether or not specified herein.This permit will expire and become null and void if construction authorized is not commenced within 180 days of the date of issuance,or if construction is suspended for a period of 180 days at any time after work has commenced. The applicant is responsible for assuring all required inspections are requested in conformance with the State Building Code.This permit may be revoked at any time for due cause. Applicant Permitee Signature Date Issued By Signature Date (7- J� Mailing Address Street Address FORLITYUSEONLY To P.O.Box 66 2750 Kelly Parkway Date Received: 5 /L `/ 7 ,gro. Crystal Bay,MN 55323 Orono,MN 55356 Permit# 2.o/ 7 IG' Is y Fs d Phone:952-249-4600 Fax:952-249-4616 Approved By: 1.(01:12,C, k stiOtt Website: www.ci.orono.mn.us Date Issued:l'sb -((D. ( I CITY OF ORONO - BACKFLOW PREVENTER TESTING PERMIT C� •�� d PERMIT CODES: City of Orono, Minnesota State Plumbing Code, Backflow Device Only THIS APPLICATION IS FOR TESTING AND REPAIR OF EXISTING BACKF OW PREVENTION DEVICES 5 Job Site Address: ,.7 r 0 old Ci yjr'--, 1300(0( R Ul Owner: j VY. '16c,k Telephone Number:J95 — H1 a— 3457 Mailing Address: 55o old crus-�.t 0 ,o( t� A) City: 447' oral / Zip: 553J`C.2 �}C !/ �Q Contractor:C-i 1 Y V iCa ?l u.Wl� � Telephone Number "/Oa' �( 3— .7'9 ' Contact Person: �'qq (fi [ 164) Li nse# PC lO' '1 3 Mailing Address l U 06'- B W19f- W�� *t �(V , ?,Q, 0K. 1562 WATER SUPPLY: Lake ❑ Well ❑ CityM BACKFLOW DEVICE: AVB ❑ PVB g Quantity I COMMERCIAL KRESIDENTIAL ❑ GENERAL INFORMATION 1. All testing reports shall be submitted to City Hall after work has been completed. 2. Provide the following information on all reports: a. Job address, Owner/Occupant. b. Testing person's name, certification number. c. Company name, address, phone and contact person. d. Description of work:test, repair or replacement.(New installation requires a separate permit) e. Location of device(s)and system being served by the backflow preventer(s). f. Make, Model, Size, and Serial Number of each device. g. Testing cycle year, testing date and or overhaul date. h. Testing results and comments. i. Report must be signed by person doing the work. PERMIT FEE CALCULATION 1. Permit Fee: $ 10.00 2. State Surcharge: $ 1.00 3. Mail-In Fee: $ 2.00 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ I'i.00 The undersigned hereby applies to the City of issuance of a Backflow Testing Permit, agrees to do all work in strict accordance with the ordinances of the City and State regulations, and certifies that all statements made on this application arue and correct. Applicant:�-� Date: 6—Mg-- Page — MPage 1 American Society of Sanitary Engineering Reduced Pressure Principle Backflow Preventer (RP) ASSE Standard #1013 Field Test Report Owner of Property PINE CORNER PROPERTIES LJ.0 .;, , •;4 Address 550 Old Crystal Bay Rd N / 7 City Orono ji tate AN'4 Zip Code 55356 Occupant of Property(if different from owner) JF1T pill a egrig Occupant Address 550 Old Crystal Bay Rd N \ f City Orono �\ .F r Sto$` .= Zip Code 55356 Manufacturer of Device: Wilkins B3 i Model#: 975XL Size of Device: 1" Serial#: 2836630 Location of Assembly and Equipment or System Application: Lawn Sprinkler/Meter Room Test Equipment: Manufacturer: Wilkins Model#: TG-3 Serial#: 091010878 Calibration Date:02/18/2015 Date test was performed: 5/3/2017 Time test was performed: 9:00 AM Static Line Pressure: Check Valve#2 Shutoff valve#2 Check Valve#1 Pressure Differential Relief Valve Leaking CD Initial Test Leaking U) Leaking (0) Closed Tight ([0) Opened at psid Closed Tight ® Closed Tight (D Pressure Drop Across Check Valve#1 _psid Describe parts and repairs when needed Leaking ([3 Leaking J]) Leaking (0) Closed Tight (� Final Test Closed Tight CD Closed Tight (0) Pressure Drop Across Opened at 3 psid Check Valve#1 5 psid Certified Tester(print)Dan Swanson Assembly Final Test Address 1880-B West Wayzata Blvd Performance City Long lake State MN Zip 55356 Phone#: ' IN • ;73-8793 Pass License#. PM05c• 3 Certi ation# 28072 Fail Signature � `i a ; 5/3/2017 Comments or Recommendations (continue to other side,if needed):