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F�arcel number: System atatus: Compliant ❑ Noncomp��an� �� (2s determined y this Iom►) Hydraulic PerForn�ance and Other Compliance , Co�mpliance Issue #1 of 4 � Da�of observation: Reason for obsenration: ...�.,. ,_ This form expires upon next in pecGon or in three years,whichever occurs first: � _.... , ,_.____� ComplianCe questions/criteria: (Required) Verification Method': (Optional) (Check!he a ro riate box (Check the approprlate box) Does the system discharge sewage to the ❑Yes �No � Searched for su�face outlet _g„round surface? _ Perfonned hydraufic test Does the system discharge sewage to drain ❑ Yes No _tile or surf�ce waters? �Searched for seeping in yard Does the system cause sewage backup ❑Yes No ❑ Checked for backup in home inta dwellin or estabiishment? ❑ Excessive ponding in soil systemlD-boxes Do other skuadons exist�at have the . ❑ Yas No �Homeowner testimony potential to immediately�nd adversely impact or threaten public health o�safeiy ❑ E�camined for su�ging;n tank eleccrical,unsafe covers,etc. ? ❑ "Black soil"above soil dispersal system Any"yes"answerindlcates that the system is an fmminen! threat to public hea/th a»d safety. ❑ System requires•smergency'pumping _ ❑ Performed dye test �oes the system pose a ihreat to ground ❑Yes No � p�er: _.,.._ ___�___._. water for any�nditions deemed non- '—"-� rotective as deteRnined b the Ins rt "Yes"lndfeates that the system/s failing to protiect . __... .— ..... . . ground water.!f"yes'; descr/be bhe cond)tlon noi�ed: �� 'No standard profocol exists. 1"his list is not exhaus(i�e, _,,, in sequential order, nar does it indicafe which combinatioRs a�nc�cessary to make this determ;nation. Certification This form Is io be compl�tsd and atteched to the Summary Form of the Mic►nesota Pollution Contrel Agency's (MPCA)Compliance Inspection Form for E�tisting Subsurtace Sewage Treatment 5ystems. Ohservations,i�terpretatians, and conclusions must be completed by an inspec�or. Complete farm must b ubmlcted to the local unit of government wichin 15 days. Pro ert owner name(s)r V a ------. ��•- -•--��- P Y �^-- Property�ddress: � • ---------- - -- Property qi+n►n r's address(if dit�rent): County: Phone: _.__. , f hereby aertlfy that/personally made the observations, interpretations, and conclusions reported on th;s form and that they are correct. Name: ��1 � 1 V Y1� Certiflcation number: ��1 _.,... Business license name and�umber: �1�la C��UI'�O _��V�LQS �� ._.__, , . ..._. or Name of local unit f over ent: —.. Sig n ature; D ate: �_...—--...—....--•--- wq-wwists4-.31 Camplinnce Inspection Form for Exiscing SSTS 4l1/08 90/Z9 3�Jdd ZTtEEL8Z96 6Z�bt tt0Z159/50