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93,/26/20Q8a 1e:16 7634988290 RUSTYS PERC TESTING PAGE 93 <br /> � 1/29/OZ W�+'/Wastewater-IST5�4.31 <br /> Compliance Inspectaon Form for Exi.�tting <br /> Individual Sewage Treatme�rt S�Istems Minnato�ta Pollutlon <br /> Contrd A�enc11 <br /> CorrwplefiNa►of this/am/u�lla the rr�imel rsqu�i►ernents c�A�n. Stet§115.55(2009)end A�inneso?s R.ch. 70�(1899). Plea�e <br /> refer to lor�or�ar�cea Aor ofher�ev�or NMo�n�eE�on.especia�py li�r oon►�p/+�enae�eqe�aementa fa bedrvom eddlEbna. <br /> � <br /> D�tie vf Ilwpec,�011:03/25/Q�, REA90N�01'Illspa�i011: �T�anel�er <br /> ProPertY 4wner(s)�Ma�o�m T�ha�e( ) <br /> p��ron reque�p i�pectio�: Miml Rv�e�ue Telepbo�e(952) �75-2�411 <br /> 5ibe Address: 2054 SlloneNne Q� C�ly: O�n� t!p Code 55356 <br /> Fbe No./ParoN No. Coun�: � Tow�tltqr <br /> �� <br /> L,ocal Regul�ory Ayda�it�;�d Onono <br /> Daba s�n aar�bvc�ed: 7/i7�Zoo6 9�n in Shor�eland Area� no 9ysbem lo Wellhe�d <br /> Pro�ec�ion Aroa: yPs� 9�n sa�vUg a MON Noensed facNll��: yps� Locsl Pa�mmit# (if anY) 1004Z __ <br /> Sysbe�as bullt prio�bo Aplil 1, 1996 snd rat bcated M 9y�arts loc�ted in Stforeland vr Wellh�d Pnotectlon <br /> Shonatand or Wellhead Probeclion A�or Se�rving a Food, Areas or Serving a Food. 8everage or Lod9i� <br /> BeMerBge or L�O�dg�g Estabpslxnent E�abl[s�uner�,Or Sys'�r�s Bu�t alber <br /> Mdrd� 31 1996 <br /> is tl�e srs�ein an Mu�t thr�st m oubllc l�eattl� <br /> �.(a�an�r es aen IIP�sy�tan) or�efal.v?!a yes�r'�ar�1TP1�/Ssysla'n� <br /> -OlscJ�arge of 9ewape Lo tt�e ground�rtace? YF5 NO -Dlsdwrge of 9ewrdge 6n tt�e grvund surfaoe? YES <br /> -DE�d�arge cf sew�e tio drair�e or surfaoe waber5? VE5 NO -Di�daige a�sewage b�draN�e or sixFaae wa6ers�YES <br /> -Sew�ge 6acloup in0o dwel�ng? Ye5 NO -Sew�ge b��dwp in�o dw�dlin� YE'S <br /> -Sih�atlon wNf�ff�e po�entlal�o Immediabely ane -Sl�,�don wlth the poEend�l to immedi�ely and <br /> ad�erseN Mnpact or tMeeben p�bYc hael�h or ad�ersel�►Nnpact ar tl�ee�puWk health� <br /> s��fety7 YES NO saf�.y� YE5 N� <br /> rs�m falllna?!�y�s an�er ls a l�9 sYslam) is!ha sva�em fallina?ta y�s a�e,r fs a laNin�9 s�ml <br /> -�,ess tna�,iw�o r���s�o�►� -�ess wa�TM�r�x a�v�a�se�aao�ae�, <br /> �n bamom end satiura0ad s�oi or bed�odc? YE5 NO sy�ern bamom and saaura�ed soil or bedrodct YES <br /> -A�P�►�V�.d�1��a'�9 Pit't 1�3 WO -A saePa9e pR�aesspool�dMtieN,or le�chi�9 p�;' Ye5 <br /> -Is V�e sys�sm�egula�ed under a monibrir�g plan ot - Is the sysbem regula�ed under a moniboring plan � <br /> ��d�9 P�iCt ("d no, gn d�peg�e 2) �5 No operatlrq permil?('d no, go bo Page 21 YES � <br /> If y�s, If yes, <br /> -Has the�+aquined moni�oring tak�en place? 1rES NO -F�s the�equi�mOnf�orit�g taken plaoe� Y�5 NO <br /> (If no,me aYa�n is r�on-�or►�p1YN+g1 (Kna rAe sy�am is►wn�o+�A�Y�91 <br /> -The monihoring ir�Cabe that fhe system meets -T'he moni�ring indica�e thst the system meets <br /> peAormance enpec�ions? Ye5 NO peAcxmance expeclstions? YES NO <br /> (If no, the sys�em fs non-corr�pMn91 (/i no. t�e s�stem!8 non-comph'��91 <br /> Page 1 of 2 wq-wwist94.31 <br />