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� Parcel number. System status: ❑ Compliant �Noncompliant (as deterrnined by this fom►J Hydraulic ertormance and Other Compliance Compliance, Issue #1 of 4 D�te of observatiion: G{ -a-(�u Reason for observation: �.��„r Tt�is form expires upon next inspection or in three years,whichever occurs first: ' Cbmpliance questions/criteria: (Required) Verification Method*: (Optionaq ' Check the� ro riate box Check the a ( ppropriate box) Does the system discharge sewage to the �Yes �No round surface? ❑ Searched for surtace outlet Dces the system discharge sewage to drain ❑Yes ❑ No ❑ Performed hydraulic test tile or surface w ers? � Searched for seeping in yard ��g Does the system cause sewage backup ❑Yes ❑ No ❑ Checked for backup in home , into dwellin or e�tablishment? ❑ Excessive ponding in soil system/D-boxes � Do other situations exist that have the �Yes ❑ No � potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safety ❑ Examined for surging in tank electrical unsafe covers etc. ? Any"yes"answer indfcates that the system/s an imminent ❑ ��Black soil"above soil dispersal system thnat to public h�alth and safety. ❑ System requi�es"emergency"pumping ❑ Pertormed dye test Does the system pose a threat to ground ❑Yes ❑ No water for any conditions deemed non- ❑ Other: ' rotective as determined b the ins ector? "Yes"indicates that the system is failing to protect ground water.lf"yes'; describe the condition noted: "No standard protocol exists. This list is not exhausfive, in sequential orrler, nor does it indicate which combinations are necessary to make this detemtination. � Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurtace Sewage Treatment Systems.Observations, interpretations,and conclusions must be completed by an inspector.Completed form must be submitted to the local unit of government within 15 days. Property owner name(s): _�/�p./�'� �/1C�w�..�,^,� Prope�ty address: a�4j � �� Property owner's address(if different): � County: I-}'�i�,11„a,'G'�?��„a Phone: (01Z-- 9 1� - �01�d ) 1 he�by certify thaf I personally made the obsenrations,inferpretations, and conclusions raported on this forrn and that they are co►rect. Name: ��'� 6� �(�,��,y��S Certification number: fv;�7 Business license name and number. S-� �(`Q'�$�-�� ,, ��,,�,.�� ? .� �� .��,L f a� Name of local unit of government: Signature: �- �i. ••-�.,.....�.._ Date:°►� -p�, wq-wwists4-31 Compliance lnspection Form for Existing SSTS 4/1/OS