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. . . µ�,."� y "�,y,F:::�.�..., M, ��f( . . � ���'.e�+k,T����i...'. <br /> . . _:<+►,..•,y{. . a <br /> � .� � .. . � � �. . . - . . <br /> � Compliance Inspectio� �orm for Existing <br /> � Individual Sewage Treatment Systems _ -�.�,�;�a��� <br /> «� , .... <br /> This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 � �,,,,� <br /> . ., .k^.71� <br /> Minnesota Pollution Control Agency <br /> Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local <br /> Unit of Government. <br /> Date of Inspection: ,�`�� - -=� —r. ! <br /> , .. <br /> Property Owner(s) ��;���C. :'� lr`-,rf4 Jfi tJ.�'.✓:��'� Telephone�':� �i��GD- �S��- <br /> Person requesting inspection(if different than owner) Telephone( ) <br /> Reason for inspection: <br /> Site Address .�� f{C� ,.� � ;� ��' �- -r City C' �%c:n..; �- <br /> Zip Code Unit o�'Government Regulating this property <br /> Fire No. Parcel No. Township Name <br /> Township Range Section Quarter <br /> (Check appropriate sewer system component and indicate location on site sketch). <br /> ank s : Soil Treatment System: Other�briefly describe�: Flow Meter <br /> �Septic tank Rock trench _Alternative system <br /> _Aerobic tank _Gravelless pipe trench _Experimental system Yes �'��No <br /> 1 Pump tank Chamber trench _Warrantied system If yes, ``� <br /> Holding tank Seepage bed Exp.Date: <br /> _Other ,�Mound _ Other <br /> _At-grade <br /> Svstem Classification <br /> System Built Prior to April l, 1996 and not Located in Any System located in Shoreland or Wellhead <br /> Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or <br /> Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after <br /> April 1, 1996 <br /> Is the system an imminent public health threa�(IPHT)?U�grade Is the system an IPHT? Upgrade <br /> 1.Discharge of sewage to the ground surface? '' YES -'NO ]0 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo <br /> 2.Discharge of sewage to draintile � - 2.Discharge of sewage to draintile or <br /> or surface waters? YES 10 mo surface waters? YES NO 10 mo <br /> 3. Sewage backup into dwelling? YES � 10 mo 3.Sewage backup into dwelling? YES NO 10 mo <br /> 4.Situation with the potential to immediately and 4.Situation with the potential immediately and <br /> adversely impact or threaten public health or adversely impact or threaten public health or <br /> safety? YESj�O� , ' 10 mo safety? YES NO ?0 mo <br /> � `�'"� Is the s stem failin � <br /> Is the svstem failing. Y g• <br /> 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between <br /> system bottom and saturated soil or bedrock? YES�? LGU** system bottom and saturated soil or bedrock? YES NO LGU** <br /> 6.A seepage pit,cesspool,drywell,or leaching pit? YES r N(�,' LGU** 6.A seepage pit, cesspool,drywell,or leaching pit?YES NO LGU** <br /> **LGU=Local Unit of Government ordinance must specify the time period within which the system must be upgraded. <br /> STATUS OF THE SYSTEM <br /> Based on the compliance criteria above the system status is (check or�e) in compliance(functioning)0 failing�n imminent threat <br /> therefore,this document is a(check one)0 Certificate of Compliance,�Notice of Noncompliance. <br /> t <br /> � Page 1 of 2 <br /> {; <br /> <i <br /> , : ; , <br />