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..,..•..,- ._ R:.ac ir�`�E S'd10s1''°R' i-.m-a- P'!1Fwv'ffi.,R'.,.v-ar•-�*p�[t. �ws+�F+iS�," ..,�+.P F�,maS 7�l .?'�'.�' '7'�''!�$�'i%�'�i,°./� a.'�'.g�i�.'.V, ° Compliance Inspection Form for Existing Individual Sewage Treatment Systems RECEIVED This form reflects the requirements of the 1996 version of MN Rules Chapter 7080 OCT n 9 2001 Minnesota Pollution Control Agency CITY OF URONO Note:Local inspection standards may be more or less restrictive than the state requirements. These differences must be made available by the Local Unit of Government. Date of Inspection:/CP•- ' Property Owner(s)Z&A0 A01wy A.2 dC c�S/ Telephone( ) Person requesting inspection(if different than owner) Telephone( ) Reason for inspection: Site Address Cityi!!5A411A,3 Zip Code Uni of Government Regulating this property d,;7 Fire No. Parcel No. Township Name dr Township Range Section Quarter (Check appropriate sewer system component and indicate location on site sketch). Tanks : Soil Treatment System: Other(briefly describe): Flow Meter Septic tank _Rock trench _Alternative system Aerobic tank _Gravelless pipe trench _Experimental system Yes Pump tank _Chamber trench _Warrantied system If yes, Holding tank _Seepage bed Exp.Date: Other Mound _ Other At-grade System Classification System Built Prior to April 1, 1996 and not Located in Any System located in Shoreland or Wellhead Shoreland or Wellhead Protection Area or Serving a Protection Area or Serving a Food, Beverage or Food, Beverage or Lodging Establishment Lodging Establishment, plus all systems Built after April 1, 1996 Is the system n imminent public health threat IPH a Is the system an IPHT? Upgrade 1.Discharge of sewage to the ground surface? YES/90.,) 10 mo 1.Discharge of sewage to the ground surface? YES NO 10 mo 2.Discharge of sewage to draintile 2.Discharge of sewage to draintile or or surface waters? YES 10 mo surface waters? YES NO 10 mo 3.Sewage backup into dwelling? YES 10 mo 3.Sewage backup into dwelling? YES NO 10 mo 4.Situation with the potential to immediately and 4. Situation with the potential immediately and adversely impact or threaten public health oradversely impact or threaten public health or safety? • YES 10 mo safety? YES NO 10 mo Is the system failing? Is the system failing? 5.Less than TWO feet of vertical separation between 5.Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES LGU** system bottom and saturated soil or bedrock? YES NO LGU** 6.A seepage pit,cesspool,drywell,or leaching pit? YE LGU** 1 6.A seepage pit, cesspool,drywell,or leaching pit?YES NO LGU** ** LGU=Local Unit of Government ordinance must specify the time period within which the system must be upgraded. STATUS OF THE SYSTEM Based on the compliance criteria above�h,system status is (check one in compliance(functioning)❑failing 13 an imminent threat therefore,this document is a(check one Certificate of Compliance otice of Noncompliance. Page 1 of 2