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Mar. 28. 2013 1 :46PM No, 1514 P. 9 <br /> Parcel number: � System status; �Gomplfant ❑Noncompliant <br /> (as detertnlned 6y this(onn) <br /> Tank Int�grity and Safety C4mpliance- Compl;ance lnspection Form fvrExisfing S57'S <br /> Compfiance Issue #2 of 4 <br /> Date ot observation� 3��y�3 Reason for observation_ point of 5ale <br /> This form expires on(three years): 3112/18 <br /> Compliance questionslcriCcrie:(Required} Yerification Method�`:(Optional} <br /> Check the e �afe box (Check fhe appropriete box) <br /> boes ihe system consist of a seepage ptt•, ❑Yes �I Na 0 probed tank bottom <br /> cess ool d ell or laachin it? <br /> bo any sewage tank(s)leak below their ❑Yes �NO ❑. �bservad lrnv liquid level <br /> desi�ned.°pe-ratin�d�th? ❑ Examined conshuction records <br /> If yes,identify which d EXamined empty(pumpsd)tank <br /> sewage tank leak�. <br /> - ❑ Probed auiside tank for"black soil` <br /> Any"ye8"an8wer!►idlCeteB tRBt the syslam is failing ro prolect � pressure/vacuUm chack <br /> ground watar. <br /> ❑ Other. <br /> ` 5eepege pits meefiing 7080.2550 may be compfiant if allowed <br /> in ordinance by local permitting authorily. <br /> "No stenderd p�otoco/exisls.This/isf is not exheuslive,In <br /> sequenfraf order,nor does if indicefe which combinetions <br /> ars necesaary to make thla dat�mlU►ptlon. <br /> Safety Check <br /> 1. Are mainte�ance hole cover�damaged,aacked,or appeared to be struch�ralhr unsound? ❑Yes• 0 No <br /> 2. Ware rttafntenance hole covers replaced in a sacu�ed manner(0.q.,screw�replaced)? �Yes ❑No" <br /> 3. Was secondary access restraint preserrt(saFety pan,second cover,or safety netbngl—highly recammenQed, ❑Yes �No <br /> 4. Are vthe�safetylhealth ie9ue presenCl ❑Yes" �No <br /> Explain' <br /> •System is an fmmMent threat to publJc healrir and sefety. <br /> C,ertificatlon <br /> Thls 9erm is to be completed and att�ched to the SummaYy Form of the Miqnespte Po1lu�on Control Agency's(M PCA)Compllance <br /> Inspacnon Form fer�xfsttng Subsurface Sewage Treatmant 3ystems.Observdtio�s,intarpret�tlons,end conclusiens must be <br /> completed by an Inepectnr,ma�ncainer,or earvice provlder.Completed fo�m must be submittad to the local unK of government within <br /> 15 days. <br /> Propelty oWner name(s): ��rli adq IIbllchellA Jahn <br /> Property address: 2805 Somerset Lano Long Laka,MN 55366(Orono) <br /> Properry ownePs eddress(ddifferent�: _ <br /> County; Hennepin P�operty owner phone: 612-850-951U Mark <br /> 1 heieby certrfy tliaf 1 peisorially mede 1He o6serv8tioris,inferpfetaNdhs,and coriclu�iaR�r6pOrfeal on t1fi�for/n end that they 8�e <br /> correcL <br /> Name: James Braegelmann Cectificaiion number: ^ <br /> Business fiCense rlame a�d number, Elmer J.Peterson Co_ Licerls�219 0� <br /> Narile of Idc�l u cvElnment� <br /> Signature; ���� �_._ Date: ��2�13 <br /> www.pca. e.mn.us • 651-296•6340 . 800-657-3854 • TTY 651•282•533�or BOD•557•3864 . AYaitable In alternatfve formats <br /> wq-ww�sts4-31 • Al Z4109 Page]of 8 <br />