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07/18/200� 1:58 7634975e11 SPTESTINGINC PAGE 0?/10 <br /> Pa�l number� System status: ❑ Compllant [�Noncomplient <br /> (as dete►mined by fhfs forrn) <br /> Hydraulic P �rforimance and �#�er Co�tr�pllanee <br /> Compliancl� I sue #1 of 4 <br /> Date of observ�atio : �-\-p$ __ �eason for observAllon: �sd��.�"�'' <br /> This i+orm expi�kes �on next inspection or in three years,whlchever occurs first: 1 �1.�-7�D�� <br /> Gontpllance�qu �tlons/criterla: (Requi��d) Veriflcatlon Method�. (Optional) <br /> __�__(Check fh a riate box , � (Check the appropriaPe boxJ <br /> Does the sys Schar�e sewage to the I]Yes �No ❑ Searahed for surFace outlet <br /> _ground surta ? -- — <br /> ❑ P�rformed hyd�aulic test <br /> Doe�the syst d acNerge sewage to drain ❑Yes l� Nu � Searched for sveping In yard <br /> tile or surtace te ? .-- <br /> Doas the systekn c se sewage backup ❑Yes [�No ❑ Chocked for badcup in homQ <br /> into dwelHng�o es lishment?,,, ..— ❑ �ccesalve ponding In soil system/D-boxes <br /> Do othe�situa�on Wdst that heve the ❑Yes �Na ❑ Homeowner testimony <br /> potentisl to im fied tely and adversely � �xamined for surging in tank <br /> impact or th�ealten ublic health or safety <br /> ele�tricaJ uns �vers,etc.�?„ _ ❑ "81ack soil"ebove soil dlspersal system <br /> Any"yes"ans�+►er ndlcabes that tHe system/s an ir»minent �] System requires"emergency'pumping <br /> thrsat ro publla he hh and safeiy. <br /> �,,,,_��_ (] Performed dye test <br /> Does the systeiln p ie a threat to ground C]Yes �No ❑ Other, _ <br /> water for any cqnd' ons deem�non- """ <br /> rotective as d' r ned the Ins� ector? _._ <br /> "Yes"indicat�s �t d�e systpm is failing to probec! ' __ <br /> ground water.l lf" '; descrJtie the condition noted; �No standaM p►vtocol exists. This list is�oi�xhausave, <br /> _,._�_. __ _ _ in sequenNal ord9r, nor does it indicafe wh/ch <br /> combinations are necessery to make thls determination. <br /> Certificatic�n . <br /> This form is to e pleted and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compllance <br /> Inspection Fo� Eacisting Subsurface Sewage Treatme�rt Sys#ems.ObservaUons,irrterpretetions,and conciusions must be <br /> completed by ah in pector.Completed form must be submitted to the local unit ad govemmertt wlthin'15 days. <br /> Property owner�na (s): e ._ :¢.� . <br /> Propetty addre s: 9� 5��� - "' ��'���'��. <br /> Prope�ty owner�s a dress(If differeM): <br /> County: 'a�. , Phone: �,��2��-"�'S��-��'Z��-_�..._..__ <br /> 1 hereby certlfy�he i personalry made H�e observativns, inl�e�r+etAdons, and conclusions reported on this fo�m and tHat they ere <br /> co�ct. i <br /> Name• � Q�. $��,�f'�,��, _, Certificafion�number. �_7 <br /> Business Ilcens�e n me and number. �=�'_'`�iS'��.�1��� � ��21�3-'����-��e..4.So�c or <br /> N�me of local u It government: _r , ..•.�---�-••.....-,.�— <br /> Signature: ���-- „ Daie: r,.��=�_ <br /> ,�,,,_,N,�„�r�q.;� i CompUance Inspection Form for ExisCing SSTS <br />