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' ����� ���� <br /> � � <br /> , � <br /> Water/Wa�tewater-ISTS431 /�� ',,�' <br /> Compliance Inspectioo Form for Existing `�l� <br /> � Individual Sewage Treatment Systems <br /> v- <br /> This form reflecis the requirements of the 1996 version oj MNRules Chapter 70$0 <br /> iVIinnesota Pollution Control Agency <br /> Note:Local inspection standards may be•more or less cestricrive than the state requirements. These differences must be made available by the Local <br /> Unit of Govemment. <br /> Date of Inspectio�' ��� �� .�s <br /> Properiy Owner(s) � � Telephone( ) <br /> Person requesting inspecri n(if diff owner) Telephone(�;.r� _-�t���' <br /> Reason for inspection: <br /> Site Address `� ' C�h,�_�����,�_,,, <br /> Zip Code Unit of ovemment Regulating this property___�,�.,,,s�- � <br /> Fire No. Parcel No. Township Name f�-.���r�e.�- ' <br /> Towaship �,n.r,'�yl,�^'�" Range Sec4on Quarter <br /> (Check appropriate sewer system component and indicate Iocalion on site sketch). <br /> Tank S Soil Treatment S stem: Other(briefly describe): Flow Meter <br /> �Septic tank/D�L' �Rock trench� � _Altemative system <br /> Aerobic tan Gravelless pipe crenc � Experimental system Yes I'�I <br /> _Pump tank _Chamber trench _Warrantied system If yes, � <br /> _Holding tank _Seepage bed Exp.Date: <br /> _Other _Mound _ Other _ <br /> _At-gade <br /> System Ciassification <br /> System Built Prior to April 1, 1996 and not Located in Any System located � Shoreland or Wellhead <br /> Shoreland or Wellhead Protection Area or Serving a rotection Area or Serving a o� , erage or odging <br /> Food, Beverage or Lodging Establishment Establishment, plus all systems Built after <br /> April 1, 1996 <br /> is the system an imminent public health threat(IPHT)?Up�rade Is the s stem an IPHT? U rade <br /> 1.Discharge of sewage to the gmund surface? YES NO 10 mo 1.Discharge of sewage to the ground surface? YES 10 mo <br /> 2.Discharge of sewage to draintile 2.Discharge of sewage to draintile or <br /> or surface waters? YES NO 10 mo surface waters? YES '� 10 mo <br /> 3.Sewage backup into dwelling? YES NO 10 mo 3.Sewage backup into dwelling? YES �NO 10 mo <br /> 4.Situation with the potential to immediately and 4.Situation with the potential immediately and <br /> adversety impact or threaten public health or advezsely impact or threaten public health or � <br /> safety? YES tV0 10 mo safety? YES O 10 mo <br /> Is the system failing? Is the system failing? <br /> 5.Less than TWO feet of vertical separation between 5.Less than THREE feet ofvertical separation between <br /> system bottom and saturated soii or bedrock? YES NO LGU" system bottom and saturated soil or bedrock? YES NO LGU'* <br /> 6.A seepage pit,cesspool,drywell,or leaching pit? YES NO LGU'�' 6.A seepage pit, cesspool,drywell,or leaching pit?YES LGU*" <br /> '*LGU=Local Unit of Government ordinance must specify the time period within which the system must be upgraded <br /> STATUS OF THE SYSTEM <br /> Based on the compliance criteria above the system status is (check one)L�in compliance(functioning)�failing�an imminent threat <br /> therefore,t6is document is a(check one)�Certificate ofCompliance ❑Notice ofNoncompliance. <br /> Page 1 of 2 wq-wwists4.31 <br /> . <br />