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05/08/2009 14:20 9528733112 PAGE 07109 r , Parcel number: _ _ System status: Compliant ❑ Noncompliant (as determined by phis brm) Hydraulic Performance and Other Compliance Compliance Issue #1 of Date of observation: iwi I Reason for observation: This form expires upon next inspection or in three years, whichever occurs first: Compliance questions/criteria: (Required) Verification Method": (Optional) Check the pp propriate box (Check the appropriate box) Does the system discharge sewage to the ❑YesNo round surface? Searched for surface outlet Does the system discharge sewage to drain ❑Yes KNo ® Performed hydraulic test -tile or surface waters? / Searched for seeping in yard Does the system cause sewage backup ❑Yes ❑ Checked for backup in home into dwellln or establishment? P(No ❑ Excessive ponding in soil system/D-boxes Do other situations exist that have the ❑Yes ?(No potential to immediately and adversely ❑ Homeowner testimony impact or threaten public health or safetyExamined for surging In tank electrical,unsafe covers,etc.)? Any"yes"answer indicates that the system is an imminent ?r-11--! Black soil"above soil dispersal system threat to public health and safety. ❑ System requires`emergency'pumping Does the system pose a threat to ground ❑Yes 7No El Performed dye test water for any conditions deemed non- ❑ Other: protective as determined by the inspector? "Yes"indicates that the system Is failing to protect ground water. If"yes". descrfbe the condition noted: No standard protocol exists. This list is not exhaustive. -� in sequential order, nor does it indicate which combinations are necessary to make this determination. Certification This form is to be completed and attached to the Summary Form of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Form for Existing Subsurface Sewage Treatment Systems,Observations, interpretations,and conclusions must be completed by an inspector. Completed form must be submitted to the local unit of government within 15 days, Properly owner name(s): y�Q� Property address: Property owner's address fif different): County: _ [�.� Phone: I hereby certify that/personally made the observations, interpretations, and conclusions reported on this form and that they are correct. Name: , � a Certification number: 9�..rt Business license name and number: ,-, ^� or Name of local unit of rent: Signature: _ Date: wq-wwists4-31 Compliance Inspection Form for Existing 55T5 411108