septic info - Laserfiche WebLink

Home Browse Search

2/25/02 Water/Wastewater-ISTS4.31 Compliance Inspection Form for Existing Individual Sewage Treatment Systems Minnesota Pollution IMP 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: 'rr: Reason for inspection: r1 e Property Owner(s) 7;� z��i,� �" Telephone&!� 7 3�� Person requesting inspection OK l Tel phone( ) Site Address t City ti Zip Code �! Fire No./ Parcel No. County Township 2126 %�= Legal Description i�/(� 3 Jig a:!)4.1 2 n o 1'2, Local Regulatory Authority o Date system constructed J U - l C�Z— System in Shoreland Area: yet o /System in Wellhead Protection Area: yesno System serving a MDH licensed facility: yes a Local Permit# (if any) a- 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 Is the system an imminent threat to gpblic health or Is the s rn 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? YESNO -Discharge of sewage to the ground surface? YES NO -Discharge of sewage to draindle or surface waters? YES -Discharge of sewage to drainble or surface waters?YES NO -Sewage backup into dwelling? YES N -Sewage backup into dwelling? YES NO -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? YE NO safety? YES NO 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 vert.ica!separation between -Less than THREE feet of vertical separation between system bottom and saturated soil or bedrock? YES system bottom and saturated soil or bedrock? YES NO -A seepage pit, cesspool,drywell,or leaching pit? YES ) -A seepage pit,cesspool,drywell,or leaching pit? YES NO 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 VOoperating permit? (if no, go to page 2) YES NO 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