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Z�25�pZ ' WaterJWastewater-IS7S431 <br /> Coxnpliance Tnspectiort Form for Existin9 Minne�ota Pollution <br /> � In�dividual �ewage'fi'reatment 5ystems _ ca;,tro�a�en�v <br /> a- <br /> Completlon of ihJs for.m fulfi!lsehut er�nts..orinformation�e�,eclallt$f.§ofm�ance�e,uirements.for bedroorn additions� P�ease refer <br /> to local ordina�ces fox cith�r r . , <br /> Generals � � � - . <br /> o Reason for Inspectton: �-► � � � '��`r � <br /> Date of Inspection: '�"�`��--�- � . Telephone(�►��,) M'�`''� "' �� <br /> Property Uwner(s) '�`��'�'C'�-� �-'t�l� I,al��-��" <br /> ,��u�,�.� Telephone( ) <br /> Person requesting�inspectlon . . � � Zi Code_______-. <br /> site Address cl.l�G �'1..`L�'��!�-� �``d fl`� __ City G���-�� � <br /> ' � � • County. �a'�A�+,.�,��"'}?.� Township . <br /> Fire No./ Parcet No. . <br /> Lega1 Description � <br /> �.� �� <br /> Local Regulatory Authority . . <br /> 1Date system construcled� Syst�m in Shoretand Area: yes fio System in Welihead <br /> stem serving a MUH licensed facility: yes r�o�L-uca� Permit# (if any)_�_____— <br /> Protec'tion Area: yes �i� Sy <br /> Systems built prior.to April 1, 1996 and not I.ocated in Sy.stems�located in Shoreland��r Wellhead.Protection <br /> Shoreland or Wellhead Protection�Area or Serving a•Food, Areas or SeNing.a Food;Bems Built after9'ng <br /> Beverage or Lodgtng Es�abiisliment � � Establ�shment,or sjist • <br /> March 3i 1996 <br /> Is the svstem an�imminent thr�eat to nut�lic health or �Ts the ���em an imrt�inent threat to nublic heatth <br /> sa e ? (a yes answer Is an IFPl/S system)��. �or:safe 7�(a�yes answer is an I7PH5 system) � <br /> -Discharge of sewage to the.ground surface? YES NO -Discharge of sewage to the ground surface? YES (N07 <br /> -D(scharge of sewage to dralritlie or surface wakers7 YES NO -Dlschalt'ge of sewage to dralnUle or surface waters?YES 6�,�� <br /> ..YES ND -Sewage..backup into dwelling? . �YES tN0) <br /> -Sewage backup Into dwelling? . • <br /> -Situatton wfth the potential Eo(mmed(ately and � -Sihaatlon with the potenttal to immedlatefy and <br /> adversely(mpact or threaten publfc health�or ' 'adversely impact or th�eate�publlc health or <br /> safety? . � YES NO safety7 . . YES �O,j <br /> ? �� � �g� , ) the s st�m�`ailin4? (a yes�answer is a fai/ing system) <br /> Ts the sustem failinn. (a,yesansweris.a fai/in , tem ��... � <br /> -Less thah TW(O feet of vertTcai.separatlon betwgen• ' . -Less thanrl'HREE f�et of�verk(ca4•separation�betv,ieen <br /> systam�bottom and saturated soi{or�bedrock? � �YES �NO -�systetn bottom arid saturated soll or bedrock? YES (NO) <br /> -A seepage plt,cesspool,drywell,or(eaching pit? � YES•"NO -A seepage plt,cesspool,dryweli,or leaching pit7 YES (�NO� <br /> Is the svstem nan-camaliant? . � � �Is the svstem non-comaliant? . <br /> -�ls the system regulated�under a monitoring plan or • -' Is the sysCeril�regulated under a .monitorin�g ES n .� <br /> operating permit? (if no,.go fo page 2) . YES NO � ope�atin�permit? (if na,go#o page�2) � '�, <br /> If yes, • If yes,� � � <br /> - Has the requirecl monitoring taken place? YES� NO -Has the reqUired monitoring taken plare? • YES NO <br /> (If no, the sysiem!S non-complying) ' (if no,�the�system Is non=coinplylrig) � . <br /> - Does.the monitoring indicate 3hat the sysfem meets -�. � �: �=Does;ttie monitoring indicafie�that the s�rstem m�ets No <br /> performance expectations?: � ��� � � . �'`"YE5 �,N.O �� ' .`� . pe1Y01'mat��e e�ipectatlofis? . .. .. ,. . YES <br /> . . . � � .,,, ,. ,.. .,.... . ,. . . <br /> .(1G�no, :7fia sysfem is non-corriplyfng) . � � ' � ' • (If no, ihe sy'stem 7s non-compiying) <br /> „ . • . • . . ' . <br /> Page 1 of�2 . �.. wq-w�iists4.31 � <br />