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# 11uJ1 �I1MNl!� <br /> ` ��t�`�A�C���`:� . �' <br /> Soll and Peroolarion TeaUr <br /> � 11481 Rhrerview Rd. NE <br /> 1 1 199� Minnesota Pollution Control Ageocy (NiPCA) <br /> ���Y .� Inspect�on Form for�ExistlnE Sep�ic Systems � �Ver, MN �� <br /> . <br /> ,�, . <br /> o��OF INSP CTION• ..��-/�9`� T1ME: IO'3v /a n-� WEA'if(ER CONDTTTONS: GIeAIZ !m PERMIT N 1MB .R �a�� <br /> BE�SON FOR INSPF('TION 1DENT1F1 _A7'ION <br /> ()Bcdroom or bstAroom�ddition Prope�ty Owaer(s) 11 N O C C P i c� Telephone( ) <br /> ��vu""�� Site Addcess,7o Frv SHorc_[.i�v�� D Z��G Ctry o RoN v <br /> t)Comp►ii�� Zlp COde � , .;;:,Cbnnty�L'"NNiPL� <br /> (q Property Truufcr FI�'e Na_ Towashlp Nsme <br /> ()Ot�cr y ryskm opeaed up! Y � Fuq p�ttW Coatraetor/instillcr aimc: <br /> SY�IEd � . <br /> Hai t�nk(s)ever bcco puraped7 � p Yq�Sytttw BuUt: l�Fr I • <br /> If Yts.how ottcnT UN K�vQ�=_ Fot whtt reaspp: �OutlnelY O ��RS pQ sluulsh plumbin� Qo�htr <br /> •Any rcp�ir donc on srstcm? Y � W� W�p By wbom <br /> Usa=c; O othcr escablishmtnt�dwdl'tn=Qt�aspna!Qot!►u 7 <br /> W�tcr usine aDDli�nccs:�Clothcs wuhcr�DlsAwasher N0.BedtOoms�_ No. o(occupants <br /> Ncaros�$urfscc Watcr; - Q ftpmwblCh �o��6ak�� OWh��'� W���diti0nin�wtit OSdf-ticaninQ humidiGcr in fumacc <br /> rypc of surtsee waur O�Ivtr O take p:treaa O othcr <br /> (Chcck approprii�c sewer system component and indlcue loc.atlon oo,iita=Iceteh on back otfortn). <br /> Tink(3�: Tink(�)M�terlil: Sell Tre�tment Rvite••�; �L: <br /> XSc tic tank <br /> Ac�robic tank y p��� ���� �v�ujve system (idcntify ryPc) <br /> — _�ravelleu trenth experitnental rysttm (idcntitY�YP�) <br /> _ Pump tank Mttal _����� other(idcntlty typc) <br /> _Ho�ding tank �Concrctc �p��� —' <br /> _Othu _mound <br /> • at•�tsde <br /> 7ank(s)Size:o�-lUO Q rsl, Soil t�eaemene srq tlst(i): A(�2px $!O sn.Q, - <br /> �'OMPLIAN . INSP C"i'ION• <br /> ic there or hac there•��r b n��Y evld`��.�tL � �jy�n <br /> D�schugc o�scwa�e w thc�roucsd sw�tce? � <br /> Dischargc of scwaYc to�surfsu wate� � ' � <br /> A sccpa�c pit,drywcll,ccupool or kachin�pitl Y� <br /> Lcss tha71 l}1rCC tCC.t of vCJSlCi�SCpifitjon bCtWtqt�1e.f0il uCilJTltllt ryftCfi So 1� 60;�,�•�: Lti�:.�,��c ,��t s ysT�n� <br /> boctom and satunted soil or bcdrockp �.Y NO iS zN SA TV fP 1 C U s����, <br /> Scw�ge backup into dwellinY ot otlur establishment p r q a t d y p e e�r�(� ' y�. � <br /> S�ws�ions wi�h the potentfal to lmmedtacely�nd adyersely(t npaci or dirqteA � <br /> public hcal�h o�ufetyl Y� � <br /> • i f Y ES wu answcrcd for any of t!u'abeve questioas�tlse=y;ta�(���:�p�tp�.R.ch.7080.0060. <br /> (if wcll sctbuks are violued,a ppieatjal(mm(ne��:�p,��.������) <br /> STATUS OF TH SYSTRM <br /> Bssed on the compUiau InspeetJco eoadueted abov�tb�=y=�m tvtyf'b �A I�i,(/I� <br /> • '• , therefore, <br /> this document is a /1Jp7';G.� pF NOAJ('i)M P�.IAN!' G� . `��u� ��mp��� OR failing ) <br /> (Choo�.CcNncato of Compll�oe OR Notla otNoneoepp!l�nee ) ' <br /> �: . . <br /> �EBTIFICATI�N , <br /> I hcrcby cutify u�stue of Minncsota licens�d Ins <br /> u otthe due u the top of thb toeen for the a(ta=�r'���r����������Y obiervations recorded on this form arc acc�n�c <br /> tbOvs,' No detsttttlnWpe'pttljwn bydr�ulfC p�{o�����made due to unknoWn <br /> nditions durin�system eonstru�uon,futuro wattr uutt ovtr tht Ilft Oftlis tyststtf;abuse etthe rystem��nd/or inadequate maintcnan:c ,ii o� <br /> nich will sC�crse�.af(cct the life of the systetn. <br /> In�pector's name d$t Qj�Uti , ' • <br /> p� ��� Phons No. F1-8' 9 Llunx and/or Reeisuadon Number �/(� <br /> D <br /> In3pcctor's sijn�wrc f • ( . <br /> ' _•.._-.-• -.,. —•-.--•----� I�ate �;,+,�,_ �� ��--- <br />