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.. �EC�6��D <br /> , �,i�� (� � LU�B <br /> 2/25/02 Water/�Vastewater-ISTS4.31 <br /> CI�'Y OF ORONO <br /> Complii�nce Inspecfiion horm for Existing <br /> �u� Minnesota Pollution <br /> ,,.,a,,,r Individua� Sewage Treatment Systenns Control Agency <br /> r.r- <br /> Comple�ion or t�rs form fuifills the nainimai requirements of Minn. Stat. § 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer <br /> to locai ordinances for other requirements or inrormation, especially for compliance requiremen:s for bedroom additions. <br /> Generai: <br /> � <br /> C�,ate ofi Ins{�ection:`,� ' � "- ��� Reasan for inspection: '`��F' <br /> Property O�Kner(s)---�'=;� ,-� r� �-��� ��� �-��,��� "�elephone (��.1� - "��� -c�;�l 2. <br /> Person requesting inspection � > r������� "f�lephone( ) <br /> Site Adciress .'� :� r `� ��� �.� City_ �>�����f� Zip Cocie �r.S ��lr <br /> Fire Na/ Pa�rcel No. _ _ __ County , ��✓.�' _To�rnship <br /> L�gal Descr�A�tion ---- --- — <br /> � i <br /> Lncai Rc�ufatory Authority _ C � � �'� %i;���c.�c�� <br /> --� <br /> Date systern constructed :i '=�' — �a 'lo _ System in Shoreland Area��no System in Wellhead <br /> Protection Area: yes �� System serving a MDH licensed facility: ye�'��Local Permit# (ir any) �-x J <br /> Sysem�: built priar to April 1, 1596 and not located in Systerns lacated in Shoreland or Wellhead Protection <br /> Shoreland or Wellhead Protectior Area dr Se;ving a Food, Areas or Serviny a Food, Bevera 3e or Lodging <br /> Beverage or Lodqing E�=tablishmer�t rstabtishment, or systems Built after <br /> March 31, 1996 <br /> I� the svsrt:em an imminent thre�t to pubiic tiealth or Is the sy,stem an im.minent threat to �.,ublic health <br /> ,afe�v.?!a yes answe,� is an 1'TPHS sysre�~�; or safetv? (a yes ansiver is an ITPHS system) <br /> . <br /> - Discharg`cf sewage to the groun� su�acE% YES NO - Discharg2 ef se�vage to the ground surface7 YES .N�C� .'' <br /> - Diknarge of sewage to draincile or sui�face waters7 YES NO - Discharg�of setivage to draintile or surface waters?YES �� <br /> -Sewage backup into dwelling? YES NO -S2wage backup into dwelling? YES V� <br /> - Sftua?inn w th the potential to immediarely and - Sih.iaCon with the potential to immediately and <br /> adver�ly impact or threaten public rEzlth or acversely impact or tt�reaten public heairh or <br /> safety7 YES NO safety7 Y� � <br /> Is the�ystem failing? (a yes answe�is a fail�;�y system) Is the system fai(in�3? (a yes answe�rs a failrng syster,�� <br /> - Lzss Far TWO feet of vertica� separa:ior �etween - Les�than THREE feet of vertical separation between <br /> i �^ <br /> � � , <br /> ��/�Lcl'� ��:CCqRI ef1C��ciiUt�cit�Cl SOi� Uf� J('�' ��k.�' YE� NO � 5�/SC�E'ffl burt017': 811U Sc�'CLI�aLC'd SOII Of'JrC!�OCK:' ��t> L`+�' <br /> -A seepace pit, cesspool, dr,�wel', or leacn�rg pit? YES NO -A seeoage pit, cesspool, drywell, or leaching pit? YE�NS3` <br /> i <br /> Is the svstem non-compliant? Is the swstem non-c:ompliant? <br /> - .s the system regul,�ted under a monitoring plan or I - Is the system regulated under a monitoring plan or <br /> operating pE;rmit? (if r�o, go to page 2) YES NO operating permit? (rf no, go to page 2) YES �N� <br /> lf yes, If yes, <br /> - Has ihe reauired monitoring tak�n place`? YES NO - Has tne required monitorirg taken pl�3ce? YES� <br /> (lfnq the system is nor,-compiyin�J ,Ifno, the syste!n is non-complying) <br /> - Does 'he monitoring indicate ihat the system rneets - Does th2 monitoring indicate that the system meets <br /> perforn�iGnce expec:��tions? YES NQ performance expectations? Y�ES �1 <br /> (If no, ;he systam;s��on-corrplyr��g) jlf nc, the system is non-complying) <br /> Page 1 cf 2 wq-wwists4.31 <br />