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.. ... ., ..�.. .:T�'�"S{�w'f����+yr,«A;�„��.4Ki::<ijiy:�y/�' 'S" .,y., � Y., * { . <br /> �,.t������ l��w��/ .i ..: �� :�i�k1�:�:�`.itip.yi'�: w'rsq{�jY'..y:.'.��.'eei.'�.,�w �,M'r;. <br /> I " n .: v..�. <br /> ; Minnesota Pollution Control e�ii� (MPC;A) r !� '� ��'�� <br /> ' Ynspectiun �'orm for Exrsting Septic Systems ��� �7� 4 4'�f�s+�� c#, <br /> ' •�'� s~•O<. <br /> ! �ate .� a2a•2i8o � <br /> ; 1g-�. REQUEST�D BX <br /> ; ��No. Name � <br /> , REASON FOR 1NS�iCTION Address � . �'hone ( � j��L�( i <br /> i ��perty Tr$nsfer � <br /> , �' Pao�ERnr own��R <br /> � ❑Property O�ner Request Property Owner <br /> � ❑Other � l�hone( � 6 ..';�� / <br /> Address "� / � �� <br /> County "I'ownship ` <br /> � $Y��M Wator Usin A liances: <br /> � Well Distanct.�ft. � PP �lothes Washer �i&hwa,�her f <br /> i Is system opened up? ��o Garbage pisposai <br /> ('�Yes � Fu11 [�partia! Nearest Surface Weter Ly�ft. fram <br /> j Has tank(s)ever been pumped'? [�}-Yes ❑ No ❑R'Yer ❑1�ake <br /> � I..ast um date_ ��`q CI��h ❑Pond <br /> P P � W 6 Soil Treatment Area S i z e �s q. f t. <br /> i ❑ Basement �ackup M'aintenancc �VVater Surface �.cT�vel Trench Graveless T r e n e h <br /> �] �u[�d <br /> � Year 5ystem Built 1 ,�,y �epa;��r ❑ y�� �N.� ❑ Seepage Bed ❑ Othe <br /> I� W ha t �$tt S ewage Ta.nk: #'t�s�� ���d� g Tank size <br /> Usage: (�'�esidence ❑ Seasonal Qther #2�.�2Qs��e �,ift Tank si�e <br /> jNp. of Bedrooms No. aF Occupants rank 1vIaterial: �Precast ❑Conerete Black <br /> ❑ Fiberglass <br /> f'iL°l er ,,,..� <br /> � SITE ENALUATIQN• ' � <br /> �, Y�,S NO Is there or has there ever been aqy evidence vf: 7f yes, Explain; <br /> ❑ � Uischarge of sewage to ground su�face? <br /> � ❑ � �ischarge of s.evc�agc ta a surfac;e water? <br /> ❑ �I A scepa�ge pic, drywell, cesspool ar leaching pit? �, <br /> ❑ � �ss than three feet oF vertical separacion 6etween <br /> the soil Yrc�tmenE system bottom 2nd satur$ted soil �"rI�S wus mtswered for uny ort the,siae evaluatinn r�uestions, the <br /> or br.drock? sysrer►r is failing according to A'inn, R. Gh. 7p80.060. <br /> ❑ ,� Sewagc backup in�o d�+elling or establishment? 5�,� <br /> 1� j�j Siru�,cions with the potentixl to immediateCy and �— <br /> adver�ely impact ar threaten public health or safety? � <br /> K U• b oo — <br /> STATUS OF THE SYSTFM °� � o�v <br /> Based on the findings from my IS'CS compliance inspection on the � <br /> date. ab�ve, thc systcm abave is: �'in Compliancc Q F'ailing � <br /> according to Minn. R. ch, 7b80 and the lacat orclinancc. � O O <br /> C�RTI�ICATIQN <br /> C hereby cerr;fy :,4 a scate of Minnesoca liecnscd inspeccor that my observations recorded on this form arc accurate as of the date at trie top <br /> of this torm for the sitc stated akx�vc. No determination of fucare hydraulic perfarmanc:e can be made d�e to unknown conditfons during <br /> system construction,the unkn�wn emount af water usg�e over the life of the s,ystem,known abuse of the system,and maintenance;all which <br /> will adver5ely sffect the life of the system, , <br /> �ased on the.flodings the system status is ��� ` <br /> (srcrus ufsy from above fi�tLFngs) � t B eal'C, Lt1is dOCumEnt ls a <br /> —. {Cr�rifi'rute nf Com 'ancr—pR—NDtice ' <br /> Of NonCpmp(iu,�CeJ <br /> ,•'ti <br /> �Il$�L°l".tOf <br /> �,icense Number <br /> Inspectar's s�g ture <br /> � 17ate <br /> COMMENTS �"� <br /> IC� 3�ad ��nOd�S�� M�3H1�Oh�a tt� �b78bc�b tt �9Z 9E�6Z/6Z160 <br />