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SCOTT COUNTY, MINNESOTA Permit# 14998
ISTS Pl}l\1PING/MAINTENANCE INSPECTION PERMIT n //
Owner ~Lf2 eK(". Address /7 35""'/ /,.~ Vr",r::f-a~/ 1;/<.//
I. ,/ ' r _ ./ / ...--...--..::-..
Pumper n'r /GI' (" ~ r .. c.. No. of Tanks Pumped I Total Gallons Pumped '> D CJ
Check all th: it aPPIY:6 q Residential D Commercial DRenta;
i ~PtiC D Holding D Pump Chamber D Cesspool D Abandoned D Other:
Condition of Baffles (baffles must be inspected) D Acceptable D Unacceptable D Replaced Baffles
Distance fro] n the bottom of the outlet baffle to the sludge layer
Disposal Loution (be specific >.
Did you ob.. rye a surface discharge? DYes D No
Pumped Fro n: D Maintenance Hole D Removed Tank Lid (e.g. stave)
inches
D I nspection Pipe (see below)
I have been iI formed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely
if the tank is] Lot pumped through the Maintenance Hole / Tank Lid to enable the removal of solids.
Signature of ()wner / Owner's Agent /J -Re7'~ f~Jft pum~i~ through the ~ance Hole / Tank Lid
Comments h!?/tIv,/ )lJ/f///LZ/ /
'/J . ., .
Pumper / In~pector Signature.
Only one pen ait is necessary
a separate pel mit is require for e
Date
/ /) -/ S''7fi V
Sewage Treatment System (ISTS). If there is more than one ISTS on a property,
Also, submit a permit whenever a tank is pumped for abandonment.
White - County
Canary - Homeowner
Pink - Pumper
Form#1120