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� '� � �: ' Compliance Inspection Form for Existing � Individual Sewage Treatment Systems �.�.s ;.. ,�A�� ��y This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 Minnesota Pollution Control Agency �; �;_ <: Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local Unit of Govemment. ` Date of Inspection: " G' ' Property Owner(s) %: -•` �` {''. ; �, ,::"�` Telephone( ) Person requesting inspection(if different than owner) � j"�-77\�;' lU;��?'�': Telephone( ) Reason for inspection: t Site Address ' City '�� ;r Zip Code Unit of Government Regulating this property Fire No. Parcel No. Township Name Township Range Section Quarter (Check appropriate sewer system component and indicate location on site sketch). Tank Soil Treatment System: Other�briefly describe�: Flow Meter =Septic tank Rock trench _Alternative system _Aerobic tank _Gravelless pipe trench _Experimental system Yes No Pump tank Chamber trench Warrantied system If yes, Holding tank Seepage bed Exp.Date: Other ,X Mound Other �At-grade �stem Classification System Built Prior to April l, 1996 and not Located in Any System located in Shoreland or Wellhead Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after April 1, 1996 Is the system an imminent public health threat(IPHT)?U�grade Is the system an IPHT? U�grade 1.Discharge of sewage to the ground surface? YES NO 10 mo 1.Discharge of sewage to the ground surface? YES NO ]0 mo 2.Discharge of sewage to draintile 2.Discharge of sewage to draintile or or surface waters? YES NO 10 mo surface waters? YES NO 10 mo 3.Sewage backup into dwelling? YES NO 10 mo 3.Sewage backup into dwelling? YES NO 10 mo 4.Situation with the potential to immediately and 4.Situation with the potential immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? � YES NO 10 mo safety? YES NO 10 mo Is the system failing? Is the system failing? 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between systetn bottom and saturated soil or bedrock? YES NO LGU** system bottom and saturated soil or bedrock? YES NO LGU** 6.A seepage pit,cesspool,drywell,or leaching pit? YES NO LGU** 6.A seepage pit, cesspool,drywell,or leaching pit?YES NO LGU** ,;: **LGU=Local Unit of Govemment ordinance must spccify the time period within which the system must be upgraded. STATUS OF THE SYSTEM Based on the compliance criteria above the system status is (check one)Q in compliance(functioning)O failing�an imminent threat therefore,this document is a(check one)�'Certificate of Compliance ❑Notice of Noncompliance. Page 1 of 2