HomeMy WebLinkAboutSewage Treatment Pump Record SCOTT COUNTY, MINNESOTA Permit# Z
n 7 a (_'R
INDIVIDUAL SEWAGE TREATMENT�oSYSTEM (ISTS) PUMPING PERMIT
Owner ftz& i L tj i' C/` , ld, t./ Address ) 1 l JL. ` ,
Pumpe _ C. No. of Tanks Pumped Total Gallons Pumped Gar)
Check all that apply: El Residential pi Commercial ['Rental
Bgf Septic ❑Holding El Pump Chamber ❑ Cesspool Abandoned El Other:_
Condition of Baffles(baffles must be inspected) 'Acceptable ❑Unacceptable ❑Replaced Baffles
Depth of sludge layer 49 inches ��
Disposal Location(be specific) ILC le-A
Did you observe a surface discharge? ❑ Yes IX No
Pumped From: ❑Maintenance Hole Removed Tank Lid(stave,for example) ❑Inspection Pipe(see below)
I have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely
if the tank is not pumped through the Maintenance Hole/Tank Lid to enable the removal of solids.
Signature of Owner/Owner's Agent Reason for not pumping through the Maintenance Hole/Tank Lid
Comments 1r l ����'I"f d]J
Pumper/Inspector Signaturei��I► Date /a .6" O
Only one permit is needed per ISTS.I dillirnore than one ISTS on a property,submit a separate permit for each IS TS.
Submit a permit whenever a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection.
White-County Canary-Homeowner Pink-Pumper
Form#1120