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2/25/02 Water/Wastewater-ISTS4.31 wi Compliance Inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollution Control Agency Completion of this form fulfills the minimal requirements of Minn. Stat.§ 115.55(2001)and Minnesota R. ch. 7080(1999). Please refer to local ordinances for other requirements or information,especially for compliance requirements for bedroom additions. General: Date of Inspection: Reason for inspection: Property Owner(s) Telephone( ) Person requesting innspectio Telephone( ) Site Address 0?W IAw*- City t ROA1D Zip Code Fire No./ Parcel No. County b L^✓4/ Township Legal Description Local Regulatory Authority Date system constructed �� le— '� System in Shoreland Area: yes °® System in Wellhead Protection Area: yes fD System serving a MDH licensed facility: yes r o Local Permit# (if any) Systems built prior to April 1, 1996 and not located in Systems located in Shoreland or Wellhead Protection Shoreland or Wellhead Protection Area or Serving a Food, Areas or Serving a Food, Beverage or Lodging Beverage or Lodging Establishment Establishment, or systems Built after March 31 1996 -J. Is the system an imminent threat to public health or Is the system an imminent threat to public health safety? (a yes answer is an ITPHS system) or safety? (a yes answer is an ITPHS system) -Discharge of sewage to the ground surface? YES NO -Discharge of sewage to the ground surface? YES ®O -Discharge of sewage to draintile or surface waters? YES NO -Discharge of sewage to draintile or surface waters?YES O -Sewage backup into dwelling? YES NO -Sewage backup into dwelling? YES -Situation with the potential to immediately and -Situation with the potential to immediately and adversely impact or threaten public health or adversely impact or threaten public health or safety? YES NO safety? YES Is the system failing? (a yes answer is a failing system) Is the system failing? (a yes answer is a failing system) -Less than TWO feet of vertical separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES NO system bottom and saturated soil or bedrock? YES N -A seepage pit,cesspool,drywell, or leaching pit? YES NO -A seepage pit,cesspool,drywell,or leaching pit? YES Is the system non-compliant? Is the system non-compliant? - Is the system regulated under a monitoring plan or - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2) YES NO operating permit? (if no, go to page 2) YES ld If yes, If yes, -Has the required monitoring taken place? YES NO -Has the required monitoring taken place? YES NO (If no, the system is non-complying) (If no, the system is non-complying) -Does the monitoring indicate that the system meets -Does the monitoring indicate that the system meets performance expectations? YES NO performance expectations? YES NO (If no, the system is non-complying) (If no, the system is non-complying) Page 1 of 2 wq-wwists4.31