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11f65/2910 90:47 7634975011 SPTESTINGINC PAGE 65/69
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<br /> � Parcel number: .. . ._,_____ System status: �Compliar� [)Noncompliant �
<br /> (as determined by this form)
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<br /> Hyd�uAic Pe�#ormance a�wd O#i�er Co�nplian�-- Campliance lnspeation Form for Exis�ing SSTS �.
<br /> Compliance Issue #1 of 4 �
<br /> Date of obsenratlan: �a.1d-„�c9�J_ Reeson for observatlon: ��0'0� '�rf•(.��r.,�!�.., ,�
<br /> This form expires upon next lnspectlon or in threa years,which�er occurs first: �,�„� �„_,,^ �
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<br /> Compllance questionslcriteria: (Requlred) Verificatlon Method�': (Option�l)
<br /> (Check the appropriate hox) ,__^ _ (Check the epprop�iate box)
<br /> Does 1he system discharge sewage to the [�Yes �No ❑ Searched for surface outlel
<br /> ground surface? "�,�r __„
<br /> Does the system discharge sewage io drain ❑Yes [I No � Perfomned hydraulic test
<br /> tile or surface waters7 � Searched for seeping In yard �p
<br /> Does lhe system cause sewage backup Q Yes �] No [� Checked for beckup In home
<br /> ..,into dwelling,or,establishinent?_,.,_ � Excesslve ponding in soil systemlD-boxes �la .
<br /> Do other sihi�tions exist that have the C]Y�s �No ❑ Homeowner testlmony
<br /> pokential t4 immqdi�#ely�ncJ a�versely
<br /> impect or ihreaten public heatlh or sflfety ❑ Examined fo�surging in tank
<br /> ..�electncal,unsafe covers etc. ? � � °Bladc soil"above soil dispersal system k.l�
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<br /> Any"y�rs"answerind/cates tha!tho system is an imminent
<br /> thr�at i�n puWlc hea1N►and saPety. ❑ System requires"emergency"pumping
<br /> -•,�-•.� ,-�•. ❑ Pertormed dye test
<br /> Does the system pose A threet to ground ❑Yes �No � p�her:
<br /> weter for eny conditfons deemed non- �-�'"��"' --""'°�� -"I
<br /> Drotective as dete�rnined by the inspector? �
<br /> "Yes"/ndkaMs tha!�Ne system►s falling to prot+esct N ��
<br /> ground water:If"ye�s';desaribe tha condition noted: �" ' '�
<br /> *No sEsndaM protocol exlsts. This list is nol exhaustive,
<br /> ,---,,.,------�.�-.� !n sequentlal order,nor does it indicate wl�ich �
<br /> canbinatlons ere necessary b make fhls determinetlon. i
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<br /> Certification
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<br /> This form Is to be compleied and srltached to the Summary�orm of the Minneaota Pollulfon Contro)Agency's(MPCA)Compllance �
<br /> Inspectlon Form for F�clsting Subsurface Sewage Treatment Sy�tema.Observations,interpretatlons,and conclusions must be ;
<br /> campleted by an inspector.Completed fonn must be submitted to Ihe Iocal unit of govemment within 15 days. �
<br /> Property owner name(s): -'(1�� LI�(I�4� G� '� '-- .......�„__ _ „_ �
<br /> Property address: 4.� 5 Al . �1'��,..'�_-� ^^�......'Q�?�._,.,�._O'�d.�1� I
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<br /> Properly owmer's eddress(iFdl�erent): _ , ,_,--� y ,
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<br /> County: �'1-�S...S�.'�r/'Q 1 1►.!, Propetty ow�er phone: �1�'-�'Z�"D�,'�� .
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<br /> 1 hereby ce►t!ry thal 1 personelly made the observations, ��rem►�t�ao�s, and conclosions reparted on thls form and thet they a�e
<br /> corr�ct. '
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<br /> Name: G',1�.�_rCK�r���,��J�a1��.��,"�,�� --•-.,�._,..�. Certifica#ion number b:�ry _. •
<br /> eusi�ess license name and number. �_-������C� 1►.,L ;� �,^���.t,�'�q�„_ '��1'�'' '11.�3 W��r1,�� ;��,or .�
<br /> Name of Iocal ri of gvvemme t: �
<br /> Signature: _�' ^' �r ���� ---- ......__,....�..,....�. �. ., Date: �� �Z!oZ 01 c� r ....-�
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