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HomeMy WebLinkAboutWell & Septic Record 11/10/2004 11:51 5514373481 DLR EXCAVATING INC PAGE 02 l . . ..~... MINNSSOTAOEPAI<TMEr-rt" OF HEALTH 11:::'.::;:~,~:""Q..e.l>ON WELL AND BORING SEALING RECORD ,Sco'~!: County .....in~ctnShltutvs.Ql/;rpN'D3l ITDWn~I\Ij)NlI,ml! l~etllp~o'IRQl'I!IlIlNo.:J&;.aIOlJNo'IF~nt8f'll-1"'lrn_loaI8~ Sp~i:1g Lp.e 11 IN 2:<1\' 1.0 S5 SE N"'l O!::-tob~r 22mj", QPr. ''''llIudll~/ll\!ll'l>mO_tni"IOI!IlI_\II!lICllIfltln ID n'I-,..li", 1~1 1.0CA1'JOpJ~ ' ep 1 e c,,, ~Ude_MQ"'M _mlr>LI1M _.:;n~~f A.QWFSHlS).. /'l"mmlo<<1 $trtllll Ad~';I or FI,. N\.InIbnr l1I1d CITY 0' WoII ar Dorlnu 1...hCllI:llM ::.~SIllQI. AqulIl3I' 0 Mullll1Qlllrrtr 173.'itl..Leneford Blvd_ Prio,:r Lakf~w~r:::,w." QM""._ Show 9U:d: \OE!IIUan Dr 1IiI1In or !xl""" ~ mQfl 01 W8l1 Dr bamo II'! ~C!\jol'\ i111d ~...*X" 1~llon. ~11/tWl"gp~y CJ QtI1i, DOI8Hllle OOIIW N ~ line.. rClIlle, Ih~~. CASING. ,....~:ll . \":) I .... $I9l!l1 (J P111S1k: Cl TiIllI CJ Otllm ,,~~'W~LHEAgCOM~EnO~ <i) OIlt.l~1iIt D Wan MCU.15e- I MIhMSola Wolland B<ttIng Seaill1ll No. UI,.,nel5ObI Urll~lJa Well NCI, or W.ge~ NQ. --.......-,\ IH 223~29 I I ..-...., Dalrt Wl!td or8all'lg ClNlnJIDd ZOO.. 195'l II. o,lgln.,,!l}cp\h-1J:L' &'ra'nC 'NA'fHR LEVEL I. Q MellQllMd 0 E&IIrnal8(l II. C)ball!ivf o aUovelan' : <IuI11El1\ f:rtJ+- -+-1 w T$m:~::t:;:: T -'-+: : . 1l,"'1I -+- ++h- J ,--' - - ...}..... ~.;., '-i IttlIlde: o Bll'l"ll'fllilI\10",llll ~ 11l.....f1 AQao\el1\Jnlt DW'Rf'I1' Cl Willi P'lt ODlIlillll.l II"Aqp~I'l.TY OVVN!iR'S ~^~F)COMPANY NAN!; "J2.m',=s J.,.2..l.l\1 ; ~rc;:>o~ ""'"Dr~ "IllII1"ll aMloollSll! rIllIam"III'I~'" well ~"""~~ ilOl!iio:L"IlilIIJ IItll_ . o Buticn.l Cl$ING(il Olllmlllel' 4" 0 _In,from "'om 10156 8q1;l1n>mrrAAr.I:I'*" ...nnIJlllflP!lr;elnme'IV9rtJ1,I(A.,., O"l'afl O~1l OLJllkflU'"<I' L\ L1'ft,& 0/110 , Same _In.fJ'Qm 10 1\, IJ~ Oi'lc o~, 01'10 C1'Tot!S O~lo DUnlmown _in,lrCl(11- to 0, D'l'er. 0"' CI UO~l\(1""'n WELL OWNs:t'E; NAMIU'pqMF'AN'l' NAME ! J LImes La.l..lY_ ,._ ,'W..lI n"'""r~ rfI~I'I"O pd~ Ildlf!ll(lIo(\llMn ll~ o"'n~llddI't!~jnllR(f!l1l :\oo..~ sCReENlOPEfIl HCM.,lt ..:;.Cl"een!fom '" II. Op'" Hol, 1"'", 1 S (; to 11,1 1\ Same OSSTAUCilCm, LJ F\odsIDrop P11)(I. C CMeK Valvc(s) IJ OeM!f 0 FlU 10 No Ob8ll'Ul:.'li, n Type o! ObsJ.l'\lDflonll; (Osscnbs) GeOLOGICAl M"Tl~I^1. I COLOR [HAADNEs:& Olllj fROTe I . . POnMA11ON ) lltflQ\knPtO'l.I~o:;:Ilo!ll:llm-'I~\'Ilf11111A1lllnIClllllOn'nearlrl_P\lI\.oflltl1O . I.", ..~ ..c.l..:l.:' ~f"'\,,:,,,, n J'.w--S:LP 1 Hr"Jt.,.~ ~~l"'l_ e;n ! L irne Yelle" Hartl 15C TO I Qbsm.n:rtiOrll\ removQd? CJ Yes 1:1 No '-JIIIIP Tvrm ~llh_ r:; Q 51 AI!\It\cv#,ld 0 NQ~ Pl'$38nl 0 01"'''''' 1 I") )In'HCD ug~D TO SEALANNUlAR. SPAcI:.BETWI!~:' eAS/Mas. OR C~SfNG ANO QOI Ii MOLl:.: 161c,~NDAT\Illll8f9tl9d.~ 0 ,lll1f'\lklr~'I"Ol~llrr.lllll!tJ-..lUltlttlllll'l"lpe 0 C€lsll'Il P.,.l'k1mllorVA{'Imcv~1 In.lrcm 10 II. Cl Pe fOl1l.lod Cl "fl;Plll",vl.l{1 Oe:}l;l't1e In.l~m 10 It. o Pc hmltcd 0 RefT1C1VE'r.1 Typo 01 por1om1r" 10 O~tT"r IGAOUTIN&:> r.o;ATSRIALlSlI Near, GltlIJtlll(J.Mllllt~ I (01111 D'tll!ll taman! = 94 If)a., ~n" bl\g '" ~~I*"..I~ ooj l;n Iba.l ~---n' 0 'Lei ?L """..1;......<;4 ... Ironl_LLl '..I n.. -"":,- ~ y~~r- __ II"~~ lrotn_ h;l______ fl _. V'f'l\'Tll!l ____ ~"rr.' I..... ~ ft. _ _ l'''lll~ ____.. tlt,ll~ - I A~M:AFlK.S, SOU~C;E OF DATA" OIFFIC:lA.T1E91N ~""NQ IOnlm We.u..sAND BOAINC5 . Olhoflln(ll;lllllldul'ldul1lJ1KrdW'llllClfooltrlgontUOtlE1l1Y? 0 Y(G ~ Nil HI:IWI'l\8JW'1' i.n:eN8I5C Dill f11i;Q,1&T1!RDQ CQNTFlAc::TOR Ct~.II{Tl.I'\C"l1CN . TI1I.& well or bIlrtl19 .....~ ~;sted ill llCl.'1lldll/tCtl wllh M1n!'la9t:lIEl Hu\4ll( Ol\(ll"lr.t' <1.125, Thl:llrlklm ~\lQ" ~l'll$IMCl In l!'1!~ ~Df)rt I:; lTIanIQlIl1!betltl'lTl'/ln'I!l~A, :"OCAl !;1)P'r IH 223229 ..__1__- t:itt',.."':1es-o~Jcr ,.\tiel1_ tLri.lli(\}!,.,lnc~ 'i-. ~973G a..""7I7 1/ ;;C,:;; l'J ;;;:: ~:"".''"o No JlLlUI'....Itd.t'eprentltlflt~~lIn11il - LO=o'., I De~n,sch.ucr 10/22/~6 NiI1fIO qf~/Sll1 ~DIIiirIg W.l1tJr~ 89:0l-( 13M) ~006 -?l~~)N-'_.__ li30! l00 'd .~,n!\, L" LUV)l J:4/r1VI 65HIULLtrSONDEYELOPMENT DLR EXCAvATING INC .._'(f1't~. NO. 549 P 3 ......GE 64 "SCOTr COUNTY, l\l).m~)!.SOTA ISTS P~PING/MA~NTENANCE INSPECTION PERMIT n, 'It # Owner /..J~ /2, ?,i<r AddRSl' /? 35""""/ //1 v.J'~J 1S0/ Pumper ?-I rb (" ~...,..._ -c. _ No. ofTnl<s hmped I Total Gallon.~ Pamped c:c:r-2J Checl< an thst app~:p ~esidentia) 0 COJ1lm~ial ORen~ ~~ptic 0 Rolding 0 Pump Chamber 0 CesSJlool 0 Abandoned 0 Other: COllditioa of.Bla1l1es (batncs 11lust be inspected) 0 Acceptable 0 Unacceptable 0 Replaced Baffles Permit # .. ,'" I) ", 4:::: :~' 0 Distance from rhe bottom of thc oatler baffle to the sJudge layer inches Disposal Loc~tion (1:>e specific) Did you observe a surface cllicharge! 0 Yes 0 No Pamped FroJlJ: 0 Mainlellal1ce Hole 0 Removed Tank Lid (e_g, stRve) 0 Inspection Pipe (seo:! below) I have been infolllled about the correct t2nk cleaning ~dllres and understand that 1 risk having my system fail prem"tureJy it'th", tank is not pumped'through tile Msinterllnce Hole I Tank Lid to'onable the removal oholids, Signature o(Owner / Owner's Agent . / R~ ?;.00l pumping through the ~nance Hole I Tank Lid Comment< _* I~ )/)~ 7 Pumper IIospeetorSj~atllre_ /J OlIte / /J -/ .;''?f y Only on'" permit is nece$l:ary i' Sewage Treatment System (ISTS). Jfthere'is more than one rSTS on a property, a separate permit is rcqu' or T5. Also, submit a permit whenever a tank is pumped for abandonment. White. CDIllIIY CanaIy - Homeown", Pink. PumllC!" _m~ __. ,................"--__..__.._.........,____..'.___.....;.._.___..... ...-.._..._........_\_......._..._~_..._...,........ I......,.. ....:_~-.".;'I....--. ....__>......_.........._......_........."a._..__-..,_ "-" - _..."'----_..._.~,_..._-_..---~~_. 'o 6JAN. 27. 20051 3:47PM 5514TOLLEFSONDEVELOPMENT DLR EXCAVATING INC NO.5 4 9 P. 4SE 65 ~ Mike's Septic Service 16961 MushtownRoad Prior Lake, MN 55372 952-440-1800 Invoice o....-n=. INVOIce * 1011612004 3671 BILL TO DLR Ex""Vlling 11 S4S 19O1ll St. E. :\4..;..", MN 55033 :P('i Or La-. \C.-e ffiCA..t' l t. &l U' P.O. NO. TERMS PROJECT DvCCNt-opt ,fbY ~Lf QUANTTTY DESCRIPTION RAlE I Plnnpilrg ~ S)'Slem 1 Tank AbelIcloD1na1t 1 )t..,., ,'Qn W"""l:luIIlpingCho~ 1 Scolt ~ Pcmril . 14998 Job at 17351 Ullgfbnt Blvd. 175.1)0 15.00 10.00 AMOUNT 175.00 15.00 10.00 .-..- ,'-' .",., ,..,...., ~..__..-..- '" n...k you tilT your bllSincss, lc:ny. PO~UD~& Total 5200.00