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06l2�/1999 2�:33 6124986290 RUSTY OLSON PERC PAGE �3 <br /> a <br /> Austy Olean'8 <br /> /'� Minnesota Pollution Contro! Agency (MPCA) ��Pe��T�9 <br /> �'�� inspection Form f'or Ezisting Septic S}�stems 1t�� ��w�`� <br /> Henuver, MN 553d1 <br /> ��ll�;_OF INS��I'IO\:�[LT�� TIMF 11'�e AM WEATHER CONDITIONS � � � ��� <br /> gEA�4.��OR INSPEC7lOn �� �-�!�Rn!(�C M1UA113E _; <br /> 1 D�N_T1FLCt�TION <br /> O Bedroom or bathroom adeition Froperty Owper(s) Telephone( ) <br /> !)�a��e�cc SiteAddress aaS6 ShoRE��t,�t Di� City O��vniu <br /> ()Complaim �ip COde <br /> COUfI(y �IL�J/�I P4 N <br /> (�Prppeny Tra�sfcr Fire No. Township Name <br /> O Other Is sYstem opcned up' Y N Full Partial Conlnctorllnsftlkr name <br /> ��.m <br /> Has tank(�)evcr bccn pumped' Q N Ye9r Syttem Builf• /S$ � <br /> If Yes,how oflen? S��nnES For wha[reason: �routincly Q ba4emen�backu s�u ish lumbin <br /> Any rcpeir donc on systcm? Y What • PO Q.B D g O othcr ` <br /> when gY�,�,� <br /> U�age: 0 olher es�blishment�dwclling Oseasonal Do�her — <br /> W�ter usieg�ppliancta:0 Clolhu washer�nisAwasher O Garbage dispo�el QLyhirlpoot baeh 0 Water oondiioneng un t Q5e`�,If-cle ng hum d fie�n fuma�� <br /> �e■rest Surfsee water: = O�� !t from whlch type of surfaee water Q river�lekep sVeam Q other <br /> {Chcck appropriate sewcr system component and indicatc Iocation on site sketch on back of form). <br /> �L�1� TanklslMaterial: Soi1 T��•r�,�p��; Other; <br /> �C Septie tank Fiberglacs �roek trcnch atcemative rystem (identify rype) <br /> Aerob'tC tank Plestic �gBv����y U��h ��xperimrnW system (identify typc) <br /> �Pump tank r Meta( Chsmber trrnch �other(id�nti(y type) <br /> �Holding tank �Concrcte ,�setpage bod <br /> —n�� mound ~ <br /> • �at-grade <br /> Tank(s)Siu:�(�DD eals SoR treatmenl area siu(!);f� (tpX �a.UO sq.1t. <br /> �OMp . �N _INSPF('f'rnnr• <br /> I Y BSS�nss FXD18Ul <br /> Discharge of scwage to the ground surface? �,�5 <br /> Discherge of scwage to a surface wete�? YBS <br /> A setpage piL drywell,c�pool or Iteching pit? YES <br /> Less then three fut of vertitel scparation between thc soil trcatment syslem co�t, l�p�l�N 4i tu o,c �s , ,�,v <br /> bottom and saturetad soil or bedrock? ES NO 9'�G�PA��riu^' 'to S�7u?ATCD So i�t <br /> Sewagc badcup into dwelling or otner establishmcne presently occurrittg? YES @ <br /> Situations with the potential to immediet�ly and ad.crscly impact or thrcaten <br /> public health or safety7 YES V� <br /> "if YE5+vas answcRd for any of the tbove qttestians,the system is failing according to Minn.R.ch.7080.0060. <br /> (if weU setbacks ett violated,a potential imminent threat to public health or safety may exist) <br /> STATUS OF THE SYST M <br /> [iased on fhe eomplianee inspection conducted above the system status fa '�p�='��� ' ,there(ore, <br /> (Choosc: in complience OR iailing ) <br /> this dotumen[is a p F A�oN CoM P Lt A.v�E <br /> (Choose:Certificate of Compliance OR Nodee of Noncomplier�cc ) <br /> �c7rFICnTIOIv <br /> I hereby cenify ns n sWle of Minncsola IICCnsed InSpCCtor,Dcsigner 1 or Qu■lified Gmptoyee�hai my observations recorded on this form are aecura�e <br /> is of Ihc da�e at the�op of this form for thc site slaeed above. No dcterminelion oCfuturc hydraulic performance can be made due to unknown <br /> ndiiions d�ving sysiem construeiioh,fulure waler usaee over tht li(e of the system,ebuse of Ihe system,end/or inadequale maintenancc all of <br /> rlich�vill adversely affcct�hc(ife af the system <br /> In5pCC10��5 nA�TIC_�$�(�l. '�'r"' �($pN Phone No. `1 $-87")9 1.icrn5t and/or RegiStretion Number S�1 U <br /> (Plcasc print) " <br /> / <br /> � r , <br /> lu.�,cclnr�c.i�n�lufc - / � � /�� <br /> _. _.l_ts,.---- - f)al[ � vv <br /> �' - ... _ .._ ._-- - --�^—�--- --'p/. .._ .__... _ <br /> � <br />