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Rug�08��8 fl1 : 12p Rndy Kleindl t952] -442-9281 p. 3 Parcel numb r: System status:�Compliant ❑ Noncampliant (as determined by this form) Hydrauli Performance and Other Compliance Complia ce Issue #1 of 4 Oate of obs ation: _ — Reason for observation: _Q 1��ir' �.11�$� . __ This forrn ex ires upon next inspection or in three years,whichever occurs first: ._ Complian e questions/criteria: (Required) Verification Method*: (Optional) Check he a ro riate box (Check the appropriate box) Does the sy tem discharge sewage to the ❑Yes �'No �Searched for surface outlet ground surf ce? — � Performed hydraulic test Does the sy tem discharge sewage to drain ❑Yes �No � Searched for seeping in yard tile or surfa watets? Does the sy tem cause sewage backup ❑Yes �(No ❑ Checked for backup in home into dwellin or establishment? .-- ❑ Excessive ponding in soil system/D-boxes Do other sit ations exist that have the ❑Yes �,No ❑ Homeowner testimony potential to i mediately and adversely impact or th eaten public health or safety ❑ Examined for surging in tank electrical, safe covers, etc.)? ❑ "8lack soil'above soil dispersal system Any"yes" swer indicates that the system is an imminent � System requires"emergency"pumping threat ta pu lic health and safety. ___ _ — — ❑ PerFormed dye test Does the sy tem pose a threat to ground ❑Yes �[No � Other: __. _ .— water for an conditions deemed non- rp otective a determined b the ins ectoi'? — "Yes"Indi ates that the sysiem is failing to proteci . — ground wa er.If"yes';describe!he condition noted: •�o standard profocol exists. This list is not exhaustive, in sequentia!order, nor does it indicate which combinations are necessary to make this determination. Certific tion This form i to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA) Compliance fnspection Form for Existing SubsurFace Sewage Treatrnent Systems.Observations, interpretations, and conclusions must be completed y an inspector. Completed form must be submitted to the local unit of government within 15 days. Property o ner name(s): _Dean Patterson _ �--- -�-� Property a dress: 2058 Shoreline Drive _ — ----— Property o ners address(if different): County, Henne in Phone: 612-328-1173 _._ _..__ 1 hereby c ify tha[!personally made the observations, interpretadons, and conclusions reported on this form and that they are correct. Name: ndrew Kleindl Certification number: 2926 _ — or Business li ense name and number: Jim's Excavatinq LLC --- Name of lo I unit of government: �,,��i---- Date: _��.^�V�—,--.—_ Signature: _ . Cornpliance Inspection Form for Existing SSTS