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• f <br /> � 1/29/02 Water/Wastewabd'-ISTS4.31 <br /> � a <br /> Compliance In�pection Form for Existing <br /> Individual Sewage Treatme�t Sys�e�ns Minn.�a�iu�on <br /> co��ao��r <br /> Compleda�of this fr�rm fuHids the minimal requlremenls of A�irm. Stet.§1 i6 S5(2a01)end Minnes�ota R. ch. 7080(1 a�9). Please <br /> reier to locel adinances Ibr qther requl�eme►►ta or ir�forrnadon,esaedalN Ira'compliance raqufiements fnr bedroam eddl6�on8. <br /> �s <br /> Ds�a oR Inspaction: 6/32/06 RE/�SON 1br In'pectlOn Prooe�tv Trans�ar <br /> PrOpetty Ow�far(s) Sba�[a LindQ Tele�tone(952) �75-9692 <br /> P�rspn repuaqng In�on: ]Im Rat�ing� Telephone��52) 4�-92?.5 <br /> S�e�wdress: �salem court City=�,7Jp Code 55356 <br /> Flre No./ PahOd No. County:li�nna�in Townihlp: <br /> lrega�De�iPdon <br /> I.ocal RaqulsborY Autho�ity: dtv of�rono <br /> D�te sy�t+em ca�strucbed: 6/Z5/85 Sysbs�tt in Sborelsnd Area: yes no S�ben� in Wellhead <br /> Pno�ectlon Area: yes rro 9ystem sanri�a MDN liasn�ed facilil�►: ye.s no lrocsl Pennit# (if arry),�9� <br /> Sysberr�s built piior Go Ap�il i, 1996 and not IocaUad I� S�rsbems bcated in Starel�nd or Wellhead Protecbon <br /> Sho�+eland or Welihead Pra�ection Ar�ea or Serving a Food, Areas or Serving a Food, Bev�age vr Lodgir� <br /> Beverage or Lodging Establishrr�nt Estab{ishmen�,or systems Built afbmr <br /> Mar�cfi 31 1996 <br /> is tl�a sys�m an i�nmina�threat tio niuWlc health or �s tl�s�vstem an Im�lnent threat bn oublic haaltl� <br /> �(a y�s ans�,r[s an m�NS sys�i►n) or:a�it.v�(a yes ensr�er[s an IIPHS sy�m1 <br /> -Disdtarge af sevvage to tt�e ground svrfaae? YES NO -QI9d�arge of sewage t�the gramd surfaoe? YeS <br /> -Dlsd�arge of sevvage to dralMlle or surface wabers? YES NO -Disd�arge of sewage tiu draintile or surFaoe wators�YES NO <br /> -Sewage badaup into dwelling? YES NO -Sewage bedaip i�o dwelll�g? YES <br /> -S�hiation witfi the potential tio immedi�r and -SIQ�a�on wlth tlte pobel'rtlal bo Immedfatet�►and <br /> ad�er9ely Impact or thr�0en puWk health or adver�►impac#or th�aben public trealCh or <br /> safety? YES NO safely? YES NO <br /> =s tl�svstem failina? (�yes an�is a failing sysieml Is��em fallina� (�yps a�sw�er is a fai/ing sy�m) <br /> -Le9s than 1V110 fee�t of verdcal s�arali�on between -Less than TMREE fieet of v�ca�separa�on betvueen� <br /> sysfi�n battnm and saturabad 9011 or bedrock? YES NO sy56em ba�ttom and satura6ed sal or hedrotk? <br /> -A 9eepage pit,oesspool,drywdl,or leeching pit? 1fES NO -A s�page pIR,oes�ool,dryvvell,a lea�ing pit? YES� <br /> �tl�e svabem non-comnllan!? !a tl�e�y�non-a� i� <br /> - Is U�e sys6em regulated under a mvnibaring plan or - Is the system regulated under a monitoring pla <br /> operating permit'� ('�f no, go to pege a� YES NO opereting permit? (Ii no,go to page 2) YES� <br /> IfYes. If yes. <br /> -Has the required mo�iEaing taken piace? YES NO -Has the re�uired monitoring taken place? YES NO <br /> (ff no, the system is►ron-con�plying) pf no,ihe syst�m is nor�-co►nplyMg) <br /> -The monitoring indicate that the system meets -The monitoring indicabe that the sysbem meets <br /> performance expoctations? YES fV0 perfvrmance expecb�ons? YES PIO <br /> prno, lhe syslem is non-comph�81 flf ra, the system Is rran�omPlyinyl <br /> Page 1 of 2 wq-wwists4.31 <br />