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Aug 29 08 04:21 p 763-213-0699 763-213+0695 p.2 <br /> ► ) ,� <br /> Parcel number: 1 ��� W ; . � �%��'�� System status: �CompliaM ❑ Noncompliant <br /> f {as del�nnined y hrs form) <br /> Hyd�aulic Perfo�n�ance and Other Compliance <br /> Compliance lssue #t of 4 <br /> Date of observation: ��rj--G�� Reason for observaiion: , <br /> This forrt�expires upon next inspection or in ttuee years,whichever occurs firsl: <br /> Compiiance questions/criteria: (Required) Verification Method': (Optional� <br /> Check fhe a ro riate box (Check the appropriate boxJ <br /> Does the system discharge sewage to the ❑Yes � No �Searched for surtace outlet <br /> round surface? <br /> Does lhe system discharge sewage to drain ❑Yes �No � Performed hydraulic test <br /> tile or surface waiers? � Searched for seeping in yard <br /> Ooes the system cause sewage badcup ❑Yes �No � Checked for baclurp in home <br /> into dwellin or establi"shment? <br /> ❑�Excessive ponding in soil system/D-boxes <br /> Do other siWations exist lhat have the ❑Yes (�No � Homeowner testimony <br /> poteMial to imrnediately and adversely <br /> impact ot threaten public heafth or safety (� Examined tor surging in tank <br /> electrical,unsafe covers, etc. ? - �� <br /> � "Black sal"above soil dispersal system <br /> Any"yes"answe�r lndicates Hrat the syslam is an immJneni <br /> throat b public health and sefety. ❑ System requires"emergency"pumping <br /> ❑ Pe�farmed dye test <br /> Does the system pose a threat to ground �Yes �No ❑ Other: <br /> waterfnr arry condilion5 deemed non- <br /> rotective as determined b 1�e ins ecto� <br /> "Yes"irtdicates that the sysfem!s failing to protect <br /> groynd water.!�"yes';describe the condltlon noted: <br /> •No standard protacol exists. This list is not exhaus6ve, <br /> in sequential order, nor does it a�dicate whkh <br /> cornbinations are necessary to make this dete�mrnation. <br /> Certification <br /> This form is to be completed and attached to the Summary Form of the Minnesata Pollution Control Agency's(MPCA)Compleance <br /> Inspection Form for Existing SubsurFace Sewage Tresbnent Systems.Observations, interpretations,and conclusions must be <br /> cornpleled by an inspector.Completed form must be submitted io the local unR of governmerrt wilhin 15 days. <br /> Properly owner name(s); I.Z�*— 1��� <br /> Property address f�'�� S� . t/ _ _ <br /> Property owner's address(if dif�erent): <br /> County: ��t�.�s7� Phone: �,.1���� -� �' ! C� <br /> !hereby certify that 1 personally made the obsenratians, interpretalions,and concl�sions r�eporfed on this form and that fhey are <br /> correct. <br /> Name: Certification number. �C> 7� / <br /> Busine license name and number: ��� • �- ���� s' � or <br /> Name of loca{u ' of government: <br /> , <br /> Signaiure: Date: �' --�`��- �� <br /> I <br /> wq-wwists4-31 ComplPante�nspection Fam for Existins SSTS <br /> 4J1108 <br />