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1 F I 2/25/02 Water;VVastewater-ISTS4.31 Compliance Inspection Form for Existing Minnesota Pollution Individual Sewage Treatment Systems Control Agency Completion of this form fulfills the minimal requirements of Minn. Stat. § 115.55(2001)and Minnesota R. ch. 70130(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: h,j1:4 h _ Property Owner(s) &,�Lt fly Telephone(6,14. 967-43a'-" Person requesting inspection 5&dfz Telephone( ) Site Address 3 d City •razz) Zip Code Fire No./ Parcel No. County ' ,0A1A) Township _ Legal Description 1 _ Local Regulatory Authority ! d _ Date system constructed system in Shoreland Area: es o System in Wellhead Protection Area: yes A System serving a MDH licensed facility: yes Local Permit# (F"any)j2/0_a- Systems -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 public health or Is the system an imminent threa! to public health safety? (a yes answer is an ITPHS system) or safety? (a yes answer is an ITPH.S system) - Discharge of sewage to the ground surface? YES NO Discharge of sewage to the ground surface? YES NO2 -Discharge of sewage to draindle or surface waters? YES NO Discharge of sewage to draintile or surface waters?YES 60D -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 hejlth 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 becrock? YES SNO -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 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 (!f no, the system is non-complying) (If no, the system is non-complying) Page 1 of 2 wq-wwists4._'11