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02/06/2009 10:19 7634275934 SYSTEM SOLUTIONS PAGE 03 <br /> this Parcel number. System status; Compliant, p Noncomplient <br /> (as determined form) <br /> Hydraulic Performance and Other Compliance <br /> Compliance Issue #1 of 4 <br /> Date of observation: 9 Reason for observation: rJ <br /> This form expires upon next inspection or in three years,whichever occurs first' <br /> Compliance questionsicriteria:(Required) Verification Method': (Optional). <br /> Check thea ro rfate box ' (Check the appropriate box) <br /> Does the system discharge sewage to the El Yet P No E] Searched for surface outlet <br /> around surface? ❑ Performed hydraulic test <br /> Does lhe'system disbharge sewage to drain C)Yes to No �( Searched for seeping in yard <br /> uls or surface Waters? <br /> Does the system cause sewbge backup ❑YesNo <br /> [] Checked for backup in home <br /> into dwelling or establishment? ❑ Excessive ponding in soil systemlD-boxes <br /> Do other situations exist that have the ❑Yes No Homeowner testimony <br /> potenllalto Immediately and edverdely ❑ Examined for surging In tank <br /> Impact or threaten public health or safety <br /> electrical -unsafe covers Big,)? ❑ "Black soil"above soil dispersal system <br /> Any"yes-answer indicates that the system is an Imminent <br /> [j System requires"emergency'pumping <br /> threat to public health and safety. . <br /> '• ❑ Performs d dye lest <br /> Does the system pose a threat to ground ❑Yes' No Other: aec,,k_ _M f'P0Al2 <br /> water for'sny conditions deemed'non- d <br /> protectIvy owdetermined by the ins ecW l� <br /> "Yes"indicates.thdt the•system is failing to protect <br /> ground water. if"yes; describe the cond(tfon noted. No standard protocol exists. This list is hot exhaustive, <br /> a in.sequential order,nordpes it Indicate which <br /> combinations are necessary to make this determination. <br /> 40ala 61e 'y-h -0 &71CC4- <br /> Certification " <br /> This form is to be completed'end attached to the Summary Form of the Minnesota PdOulion Control Agency's(MPGA)Compliance <br /> Inspection Form for Existing Subsurface•Sawage Treatment Systems.Observations,interprelationk,•and condusfons must be <br /> completed py an inspector,.Completed form must be submitted to'lhe local unit of government within IS-lays. <br /> Property owner name(s):) <br /> Property address: �- <br /> Property owner's address(irditf, rem Q. <br /> Phone: <br /> County: <br /> .I hereby cerfiy that 1 personally made the observations,.Interpretations, bnd conclusions?eported on this form and that they are <br /> correct -5934. <br /> w.1C kIAGENAH <br /> Name: SYSTEM SOLUTIONS-15231 Jackel St. NW <br /> Business license name and number: MPCA#1483 -Ramsey,MN 55303 <br /> Name of local unit of vamment: - <br /> Signature: Date: <br /> . t <br /> r <br />